By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by Cigna in Texas: Appeals Process, State Laws, and Approval Strategies

Answer Box: Getting Alecensa (alectinib) Covered by Cigna in Texas

To get Alecensa (alectinib) approved by Cigna in Texas: Your oncologist must submit a prior authorization request through Express Scripts/Accredo with ALK-positive test results, prior therapy documentation, and medical necessity justification. If denied, you have 180 days to appeal internally, then can request an Independent Review Organization (IRO) through Texas Department of Insurance. Texas law requires step therapy overrides when the preferred drug is contraindicated or ineffective—use this protection if facing step therapy requirements.

First step today: Call Cigna customer service (number on your ID card) to confirm Alecensa's formulary status and PA requirements, then have your oncologist begin the prior authorization process immediately.

Table of Contents

  1. Why Texas State Rules Matter for Cigna Coverage
  2. Prior Authorization Standards and Turnaround Times
  3. Texas Step Therapy Protections
  4. Continuity of Care During Provider Changes
  5. External Review and Complaint Process
  6. Practical Scripts and Documentation
  7. ERISA Plan Limitations
  8. Quick Reference: Contacts and Resources
  9. FAQ: Common Questions

Why Texas State Rules Matter for Cigna Coverage

Texas insurance laws provide crucial protections for specialty drug coverage that work alongside Cigna's policies. Understanding these state-specific rights can mean the difference between approval and denial for Alecensa (alectinib), which costs approximately $19,466 per 240-count bottle.

Key Texas Protections:

  • Mandatory step therapy override criteria under Texas Insurance Code Section 1369.0546
  • Independent external review through Texas Department of Insurance
  • Continuity of care protections for ongoing cancer treatment
  • Expedited timelines for life-threatening conditions
Note: These protections apply to state-regulated plans. Self-funded employer plans (ERISA) follow federal rules and may have different procedures.

Prior Authorization Standards and Turnaround Times

Cigna manages specialty drugs like Alecensa through Express Scripts and Accredo, requiring prior authorization for most ALK inhibitors.

Standard Review Process

Review Type Timeline When to Use
Standard PA 72 hours Initial requests, renewals
Expedited PA 24 hours Life-threatening conditions, ongoing treatment
Appeal Level 1 45 days After PA denial
Appeal Level 2 60 days After Level 1 denial

Required Documentation for Alecensa PA

Essential elements your oncologist must include:

  • ALK-positive test results (IHC or FISH)
  • Diagnosis with ICD-10 codes (C78.00 for metastatic NSCLC)
  • Prior therapy attempts and outcomes (if applicable)
  • Contraindications to preferred formulary drugs
  • Dosing rationale (600 mg twice daily with food)

Submit via: Cigna provider portal, fax, or call customer service number on your ID card.

Texas Step Therapy Protections

Texas law provides strong protections against step therapy requirements that could delay your Alecensa treatment. Under Texas Insurance Code Section 1369.0546, insurers must grant step therapy overrides when specific criteria are met.

Override Criteria

Your prescriber can request an override if they document that the required step therapy drug:

  • Is contraindicated for your condition
  • Will likely cause adverse reactions or harm
  • Is expected to be ineffective based on your clinical characteristics
  • Would disrupt stable treatment (if you're already on Alecensa)

Critical Timeline Protection

If Cigna fails to respond to a step therapy override request within 72 hours, the override is automatically granted in your favor.

From our advocates: We've seen patients successfully obtain step therapy overrides by having their oncologist cite specific contraindications to crizotinib (such as QT prolongation risk) when requesting Alecensa as first-line therapy. Documentation of cardiac risk factors strengthens these requests significantly.

Continuity of Care During Provider Changes

If your oncologist leaves Cigna's network while you're on Alecensa, Texas Insurance Code Section 1272.302 protects your ongoing treatment.

Protection Periods

Situation Coverage Duration
Life-threatening illness (cancer) Up to 90 days
Terminal illness Up to 9 months

To activate: Your oncologist must request continuity of care in writing, agree to network reimbursement rates, and not balance bill you.

External Review Process Through Texas DOI

When Cigna denies your Alecensa appeal, Texas provides an independent external review through certified Independent Review Organizations (IROs).

Step-by-Step External Review Process

  1. Complete internal appeals first (both Level 1 and Level 2)
  2. File IRO request within 4 months of final denial
  3. Submit form LHL009 to Texas Department of Insurance
  4. Cigna forwards to TDI within 1 business day
  5. IRO reviews within specific timelines:
    • Step therapy denials: 3 days
    • Other specialty drug denials: 20 days
    • Life-threatening conditions: 5 days (expedited)

The IRO decision is binding on Cigna and free to you.

Contact for help: TDI Consumer Help Line at 800-252-3439

Practical Scripts and Documentation

Phone Script for Cigna Customer Service

"I need to check the prior authorization status for Alecensa, generic name alectinib, for my ALK-positive lung cancer. Can you tell me the formulary tier, any step therapy requirements, and provide the PA form or portal link? If there's a step therapy requirement, I'd like information about the override process under Texas Insurance Code Section 1369.0546."

Medical Necessity Letter Checklist for Providers

Essential components:

  • Patient's ALK-positive NSCLC diagnosis with staging
  • Prior therapy failures or contraindications
  • Specific clinical rationale for Alecensa
  • Reference to FDA labeling for approved indications
  • Monitoring plan for liver function and CPK levels

Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing the specific denial reasons and crafting evidence-backed rebuttals that align with each payer's policies. Their platform helps oncology practices navigate complex prior authorization requirements and appeal processes more effectively.

ERISA Plan Limitations

Important limitation: If you have employer-sponsored insurance through a self-funded plan (ERISA), Texas state protections may not apply. These plans follow federal rules and have different appeal processes.

To check: Look for "self-funded" or "self-insured" language in your plan documents, or ask your HR department.

ERISA plans still provide:

  • Federal external review rights
  • Similar internal appeal timelines
  • Protection against arbitrary denials

Quick Reference: Contacts and Resources

Key Contacts

Resource Phone Website
Cigna Customer Service Number on ID card cigna.com
Express Scripts PA 800-753-2851 express-scripts.com
Texas Department of Insurance 800-252-3439 tdi.texas.gov
Office of Public Insurance Counsel 877-611-6742 opic.texas.gov

Essential Forms

Financial Assistance

Genentech Copay Card: May reduce out-of-pocket costs to $5/month for eligible patients. Visit genentech-access.com for details.

Patient Assistance Programs: Available through Genentech for uninsured or underinsured patients meeting income criteria.

For comprehensive support with appeals and prior authorization challenges, Counterforce Health offers specialized assistance in converting denials into successful appeals through evidence-based documentation and payer-specific strategies.

FAQ: Common Questions

How long does Cigna take to review Alecensa prior authorization in Texas? Standard reviews take up to 72 hours, expedited reviews 24 hours. Texas law doesn't change these federal timelines, but provides additional appeal rights if denied.

What if Alecensa is non-formulary on my Cigna plan? Request a formulary exception through the Cigna exception process. Your oncologist must document medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal in Texas? Yes, if your condition is life-threatening or could seriously jeopardize your health. Both Cigna and Texas IRO offer expedited pathways for urgent cases.

Does step therapy apply if I failed ALK inhibitors outside Texas? Prior therapy failures from other states count toward step therapy requirements. Ensure your oncologist documents these failures in the PA request.

What happens if I'm stable on Alecensa and my doctor leaves Cigna's network? Texas continuity of care laws protect ongoing cancer treatment for up to 90 days, allowing you to continue with your current oncologist at in-network rates.

How much does the external review cost? External review through Texas IRO is free to patients. Cigna pays the IRO fee.

Can I appeal if my employer plan is self-funded? Self-funded ERISA plans follow federal appeal rules, not Texas state protections. You still have internal and external appeal rights, but different timelines and procedures may apply.

What documentation strengthens an Alecensa appeal? Include ALK test results, staging information, prior therapy details, contraindications to alternatives, and citations to clinical guidelines supporting Alecensa use in your situation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for specific guidance regarding your coverage and treatment options.

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