How to Get Alecensa (alectinib) Covered by Cigna in Virginia: Complete Prior Authorization Guide with Appeals and Forms
Answer Box: Getting Alecensa (alectinib) Approved by Cigna in Virginia
Cigna requires prior authorization for Alecensa (alectinib) in ALK-positive NSCLC, with 72-hour standard review and 24-hour expedited review. Submit via Cigna eviCore portal or Express Scripts with ALK test results, pathology report, and surgical documentation (for adjuvant use). If denied, Virginia offers external review through the State Corporation Commission within 120 days of final denial. First step today: Verify your specific plan's formulary status by calling Cigna member services (number on your ID card) and gather ALK-positive test results.
Table of Contents
- Is Alecensa (alectinib) Covered by Cigna?
- Prior Authorization Process and Requirements
- Timeline: How Long Does Approval Take?
- Medical Necessity Criteria
- Common Denial Reasons and Solutions
- Appeals Process in Virginia
- Specialty Pharmacy and Cost Considerations
- Virginia External Review Process
- Troubleshooting Common Issues
- Frequently Asked Questions
Is Alecensa (alectinib) Covered by Cigna?
Yes, Alecensa is typically covered by Cigna as a Tier 4 specialty medication, but requires prior authorization and must be dispensed through Accredo specialty pharmacy. Coverage applies for FDA-approved indications:
- Metastatic ALK-positive NSCLC (first-line or after crizotinib)
- Adjuvant treatment for resected stage IB-IIIA ALK-positive NSCLC
Coverage at a Glance
| Requirement | Details | Source |
|---|---|---|
| Prior Authorization | Required for all indications | Cigna Policy CNF-494 |
| Formulary Tier | Tier 4 specialty drug | Multiple Cigna formularies |
| Step Therapy | Not required for ALK-positive NSCLC | Cigna Policy CNF-494 |
| Specialty Pharmacy | Accredo required | Cigna specialty pharmacy policy |
| Age Limit | 18 years or older | Cigna Policy CNF-494 |
Prior Authorization Process and Requirements
Step-by-Step: Fastest Path to Approval
- Verify Coverage (Patient/Clinic Staff)
- Call Cigna member services (number on insurance card)
- Confirm Alecensa is on your specific plan's formulary
- Verify Accredo is your specialty pharmacy benefit
- Gather Required Documentation (Clinic)
- ALK-positive test results (FDA-approved method: FISH, NGS, or IHC)
- Pathology report confirming NSCLC diagnosis
- For adjuvant: surgical notes showing complete resection
- Performance status assessment (ECOG score)
- Submit Prior Authorization (Prescriber)
- Via Cigna eviCore portal (oncology PAs)
- Or Express Scripts specialty PA system
- Include all required documentation
- Enroll in Patient Support (Patient/Clinic)
- Contact ALECENSA Access Solutions for reimbursement support
- Consider copay assistance programs
- Monitor Status (Patient/Clinic)
- Standard review: 72 hours
- Expedited review: 24 hours (with physician certification)
Required Documentation Checklist
✓ ALK-positive confirmation: Test results from FDA-approved method
✓ Pathology report: NSCLC diagnosis with ICD-10 codes
✓ Surgical documentation: For adjuvant use (tumor ≥4cm or node-positive)
✓ Prescriber attestation: Oncology/hematology specialty required
✓ Performance status: ECOG 0-2 typically required
✓ Insurance verification: Confirm Express Scripts/Accredo coverage
Timeline: How Long Does Approval Take?
| Review Type | Timeline | When Available |
|---|---|---|
| Standard PA | 72 hours | Standard requests |
| Expedited PA | 24 hours | Physician certifies delay jeopardizes health |
| Internal Appeal Level 1 | 45 days | After initial denial |
| Internal Appeal Level 2 | 60 days | After Level 1 denial |
| Virginia External Review | 45 days (72 hours expedited) | After internal appeals exhausted |
Note: If Cigna fails to respond to a step therapy override request within 72 hours, the override is automatically granted according to their policy.
Medical Necessity Criteria
Clinician Corner: Medical Necessity Letter Requirements
Your oncologist's prior authorization request must document:
For Metastatic ALK-Positive NSCLC:
- Patient ≥18 years old
- ALK-positive status confirmed by FDA-approved test
- Advanced or metastatic NSCLC diagnosis
- Treatment-naive to ALK inhibitors (first-line) OR progression after crizotinib
For Adjuvant ALK-Positive NSCLC:
- Patient ≥18 years old
- ALK-positive status confirmed by FDA-approved test
- Complete surgical resection documented
- Stage IB (tumors ≥4cm), II, or IIIA disease
- No prior systemic therapy for NSCLC
Supporting Evidence to Include
- FDA labeling: Alecensa approved for both indications
- NCCN Guidelines: Category 1 recommendation for ALK-positive NSCLC
- Clinical trials: ALEX trial (metastatic), ALINA trial (adjuvant - 76% reduction in recurrence risk)
- Contraindications: Document why alternatives aren't suitable
Common Denial Reasons and Solutions
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| Missing ALK test | Submit FDA-approved test results | Molecular pathology report with ALK fusion status |
| Insufficient surgical history | Provide complete surgical documentation | Operative notes, pathology showing tumor size/nodes |
| Step therapy not met | Request override with medical justification | Letter documenting contraindications to preferred agents |
| Not medically necessary | Submit comprehensive clinical rationale | Treatment history, guidelines, peer-reviewed evidence |
| Age restriction | Verify patient meets ≥18 requirement | Birth date confirmation in medical record |
Appeals Process in Virginia
Internal Appeals with Cigna
Level 1 Internal Appeal (180-day window)
- Submit written appeal within 180 days of denial
- Include updated medical necessity letter
- Attach all supporting documentation
- Request peer-to-peer review with Cigna medical director
Level 2 Internal Appeal
- Available if Level 1 is denied
- 60-day review timeline
- Final internal step before external review
Scripts for Common Situations
Patient Script for Calling Cigna: "I'm calling about a prior authorization denial for Alecensa for ALK-positive lung cancer. I'd like to request an internal appeal and schedule a peer-to-peer review between my oncologist and your medical director. Can you help me start this process and provide the required forms?"
Clinic Script for Peer-to-Peer Request: "We're requesting a peer-to-peer review for our ALK-positive NSCLC patient who was denied Alecensa. The patient meets all FDA-approved criteria per your policy CNF-494. Our oncologist is available [specific times] to discuss the clinical rationale with your medical director."
Specialty Pharmacy and Cost Considerations
Accredo Dispensing Process
Once approved, Alecensa must be dispensed through Accredo specialty pharmacy:
- Prescription Transfer: Cigna automatically routes to Accredo
- Patient Contact: Accredo calls within 24-48 hours
- Benefits Verification: Copay amount confirmed
- Clinical Assessment: Specialty pharmacist reviews treatment plan
- Delivery Setup: Secure home delivery arranged
- First Shipment: Arrives within 3-5 business days
Accredo Contact: 1-800-803-2523
Cost-Saving Options
- ALECENSA Access Solutions: Manufacturer reimbursement support program
- Copay assistance: May be available through Genentech (verify eligibility)
- Foundation grants: For patients meeting income requirements
Tip: Contact ALECENSA Access Solutions before starting treatment to understand your out-of-pocket costs and available assistance programs.
Virginia External Review Process
If Cigna denies your internal appeals, Virginia offers an independent external review through the State Corporation Commission Bureau of Insurance.
Eligibility and Timeline
- Deadline: 120 days from final internal denial
- Standard Review: 45 days for decision
- Expedited Review: 72 hours (with physician certification of urgency)
- Cost: Free to patients
Required Forms and Submission
Submit Form 216-A (External Review Request) via:
- Fax: (804) 371-9915
- Email: Bureau of Insurance
- Mail: Virginia Bureau of Insurance
Download Form 216-A from Virginia SCC
External Review Process Steps
- Preliminary Review: Bureau verifies eligibility (5 business days)
- Assignment: Independent Review Organization selected (1 business day)
- Information Submission: Cigna provides all documentation (5 business days)
- Additional Evidence: You may submit extra information (5 business days)
- Decision: Written determination issued (45 days standard, 72 hours expedited)
Important: The external review decision is binding on Cigna. If overturned, they must authorize coverage within 24 hours for expedited cases.
When to Request Expedited Review
Request expedited external review if:
- Delay could seriously jeopardize your life or health
- Your oncologist certifies that waiting 45 days would harm your ability to regain function
- You're experiencing disease progression requiring immediate treatment
Troubleshooting Common Issues
Portal and System Problems
Cigna eviCore Portal Down:
- Use backup fax submission to Cigna PA department
- Call Cigna provider services for alternative submission methods
- Document submission attempts for appeal timeline protection
Missing Forms or Documentation:
- Contact your oncologist's office for complete medical records
- Request ALK test results from pathology lab if not in chart
- Obtain surgical reports from hospital medical records department
Communication Issues
No Response from Cigna:
- Standard PA decisions are due within 72 hours
- Call member services if deadline passes
- File complaint with Virginia Bureau of Insurance if needed
Accredo Transfer Problems:
- Contact both Cigna member services and Accredo directly
- Verify specialty pharmacy benefits are active
- Confirm prescription was sent to correct Accredo location
Frequently Asked Questions
Q: How long does Cigna prior authorization take for Alecensa in Virginia? A: Standard review is 72 hours, expedited review is 24 hours with physician certification that delay would jeopardize your health.
Q: What if Alecensa is non-formulary on my Cigna plan? A: Request a formulary exception with medical necessity documentation. Your oncologist can justify why formulary alternatives aren't suitable for your specific case.
Q: Can I request an expedited appeal in Virginia? A: Yes, both Cigna internal appeals and Virginia external review offer expedited options when your physician certifies that delay would harm your health.
Q: Does step therapy apply to Alecensa for ALK-positive lung cancer? A: No, Cigna's policy doesn't require step therapy for Alecensa in ALK-positive NSCLC, though some plans may have preferred alternatives.
Q: What happens if I move from another state to Virginia during treatment? A: Contact Cigna to update your address and confirm Virginia network providers. Your prior authorization should remain valid, but verify with member services.
Q: How much will Alecensa cost with Cigna coverage? A: As a Tier 4 specialty drug, your cost depends on your specific plan's copay or coinsurance structure. Contact Accredo at 1-800-803-2523 for exact pricing after PA approval.
Q: Can my family member help with the appeals process? A: Yes, but you'll need to complete an authorized representative form allowing them to speak with Cigna on your behalf.
From Our Advocates
"We've seen many Virginia patients successfully overturn Alecensa denials by ensuring their ALK test results were clearly documented and by requesting peer-to-peer reviews when initial PAs were denied for 'not medically necessary' reasons. The key is having your oncologist emphasize that Alecensa is FDA-approved and NCCN-preferred for your specific situation. This is a composite of successful approaches we've observed, not a guarantee of outcomes."
Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to the plan's own rules. For medications like Alecensa, Counterforce Health pulls the right citations—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with required clinical facts and operational details payers expect.
Whether you're navigating Cigna's prior authorization process or preparing for a Virginia external review, having the right documentation and understanding the specific requirements can make the difference between approval and denial. Counterforce Health's systematic approach helps ensure nothing falls through the cracks during this critical process.
Sources & Further Reading
- Cigna Alecensa Prior Authorization Policy CNF-494 (PDF)
- Virginia State Corporation Commission External Review Process
- Cigna Precertification Requirements
- ALECENSA Access Solutions Program
- Virginia Bureau of Insurance Consumer Services
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.
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