By Counterforce Health Team in Alprolix (coagulation factor IX, rFIXFc; eftrenonacog alfa) —

How to Get Alprolix (Coagulation Factor IX) Covered by Cigna in Washington: Complete PA Guide with Appeal Timeline

Answer Box: Quick Path to Approval

Cigna requires prior authorization for Alprolix (eftrenonacog alfa) in Washington. Submit the Clotting Factors Prior Authorization Form with hematologist documentation, factor IX levels, and bleeding history. Route through Accredo specialty pharmacy. Standard review takes 5 business days; expedited (24 hours) for urgent cases. If denied, you have 180 days for internal appeal, then external IRO review through Washington's Insurance Commissioner. Start today: Gather your diagnosis codes, prior therapy records, and contact your hematologist to complete the PA form.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking & Status
  9. Common Denial Reasons & Solutions
  10. Appeals Process in Washington
  11. Quick Reference Checklist
  12. FAQ

Who Should Use This Guide

This guide helps Washington residents with Cigna insurance get Alprolix (eftrenonacog alfa) covered for hemophilia B treatment. You'll need this if:

  • Your doctor prescribed Alprolix for hemophilia B (factor IX deficiency)
  • You have Cigna commercial, Medicare Advantage, or Medicaid managed care
  • You received a prior authorization denial or want to avoid one
  • You're switching from another factor IX product

Expected outcome: Following this process typically results in approval within 5-7 business days for standard requests. If initially denied, Washington's robust appeal process has helped many patients overturn coverage decisions through internal appeals and external review.

Member & Plan Basics

Coverage Requirements

Requirement Details Where to Verify
Active Coverage Current Cigna enrollment with prescription benefits myCigna portal or member services
Plan Type Commercial, Medicare Advantage, or Medicaid managed care Insurance card or benefits summary
Specialty Pharmacy Must use Accredo (Cigna's preferred vendor) Cigna specialty pharmacy guide
Prior Authorization Required for all factor IX products including Alprolix Cigna formulary
Note: If you have a self-funded employer plan, some Washington state protections may not apply, but many employers voluntarily follow state external review processes.

Clinical Criteria Requirements

Primary Requirements

Diagnosis: Hemophilia B (congenital factor IX deficiency) with documented factor IX levels typically <30% of normal activity.

Prescriber: Must be a hematologist or prescribed in consultation with a hematologist specialist.

Step Therapy: Cigna typically requires trial and failure of preferred factor IX products first, including:

  • BeneFIX (nonacog alfa)
  • Rixubis (nonacog gamma)
  • Ixinity (nonacog alfa)

Medical Necessity Documentation

Your hematologist must document:

  • Bleeding history: Frequency, severity, and location of bleeding episodes
  • Prior therapy failures: Specific products tried, doses, duration, and reasons for discontinuation
  • Contraindications: Any medical reasons preventing use of preferred alternatives
  • Dosing rationale: Why the requested dose and frequency are appropriate
  • Treatment goals: Expected outcomes and monitoring plan
Tip: Keep a bleeding diary for 2-4 weeks before your appointment to provide concrete data about your current bleeding pattern.

Coding & Billing Information

Essential Codes

Code Type Code Description
ICD-10 D67 Hereditary factor IX deficiency (hemophilia B)
HCPCS J7201 Injection, factor IX, Fc fusion protein (recombinant), Alprolix, 1 IU
NDC 71104-0977-01 Most common Alprolix kit NDC for billing

Billing units: Each unit of J7201 represents 1 IU of Alprolix. Your dose will determine the total units billed (e.g., 3,500 IU dose = 3,500 billable units).

Documentation Packet

Required Documents

  1. Cigna Clotting Factors Prior Authorization Form (completed by hematologist)
  2. Medical records showing hemophilia B diagnosis and factor IX levels
  3. Treatment history documenting prior factor IX products tried
  4. Bleeding log or clinical notes describing current bleeding pattern
  5. Letter of medical necessity (if step therapy exception needed)

Letter of Medical Necessity Components

If requesting an exception to step therapy, include:

  • Patient identification: Name, DOB, Cigna member ID
  • Diagnosis: Hemophilia B with ICD-10 code D67
  • Clinical rationale: Why preferred alternatives are inappropriate
  • Literature support: FDA labeling or guidelines supporting Alprolix use
  • Monitoring plan: How treatment response will be evaluated

Submission Process

Step-by-Step Submission

  1. Complete PA form: Hematologist fills out Clotting Factors PA form
  2. Gather attachments: Medical records, lab results, treatment history
  3. Submit electronically: Use CoverMyMeds or Cigna provider portal
  4. Alternative submission: Fax to number on PA form (verify current fax on form)
  5. Track submission: Note confirmation number and submission date

Timeline Expectations

  • Standard review: 5 business days from complete submission
  • Expedited review: 24 hours for urgent medical situations
  • Incomplete submissions: May delay review by 3-5 additional days
Important: Mark requests as "expedited" only for active bleeding or high bleeding risk situations.

Specialty Pharmacy Routing

Alprolix must be dispensed through Accredo, Cigna's preferred specialty pharmacy for factor products.

Prescription Routing Process

  1. Electronic prescribing: Hematologist sends prescription to Accredo using NCPDP 2623735
  2. Prior authorization: Accredo coordinates PA submission with your doctor's office
  3. Patient enrollment: Accredo contacts you to set up delivery and training
  4. Delivery setup: Home or clinic delivery with temperature monitoring

Contact Accredo: 888-327-9791 for prescription status or patient enrollment questions.

After Submission: Tracking & Status

Status Check Schedule

  • Day 1-2: Confirmation of receipt
  • Day 3-4: Clinical review in progress
  • Day 5: Decision notification (standard timeline)

What to Record

  • Confirmation number from submission
  • Date and time of submission
  • Contact person at doctor's office handling PA
  • Accredo enrollment status and contact information

Status check methods:

  • Call Cigna member services: 1-800-244-6224
  • Log into myCigna portal for PA status updates
  • Contact prescriber's office for submission confirmation

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document failures/contraindications to preferred agents Trial records, adverse events, contraindication notes
Non-preferred brand Submit formulary exception request Medical necessity letter with clinical rationale
Quantity/dose limits Provide PK data or bleeding history justifying dose Pharmacokinetic studies, bleeding logs, weight-based calculations
Prescriber requirements Ensure hematologist involvement Specialist consultation notes or co-signature
Insufficient documentation Submit complete medical records Diagnosis confirmation, lab values, treatment history

Appeals Process in Washington

Washington provides strong consumer protections through a structured appeals process managed by the Office of the Insurance Commissioner (OIC).

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: Cigna has 60 days to decide
  • How to file: Use Cigna appeal form or write a letter
  • Include: Denial letter, medical records, prescriber support letter

External Review (IRO)

If internal appeal is denied:

  • Deadline: 180 days from final internal denial
  • Process: Contact Washington OIC at 1-800-562-6900
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Outcome: IRO decision is binding on Cigna
From our advocates: We've seen Washington patients successfully overturn Alprolix denials by submitting detailed bleeding logs and pharmacokinetic data showing inadequate response to preferred products. The key is providing specific dates, doses, and clinical outcomes rather than general statements about treatment failure.

Contact for help: Washington Office of the Insurance Commissioner Consumer Advocacy: 1-800-562-6900

For complex cases involving insurance denials and appeals, Counterforce Health helps patients and clinicians turn denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Quick Reference Checklist

Before Starting

  • Active Cigna coverage verified
  • Hematologist appointment scheduled
  • Previous factor IX treatment records gathered
  • Bleeding diary started (if not already keeping one)

Documentation Needed

  • Completed Clotting Factors PA form
  • Hemophilia B diagnosis with lab values
  • Documentation of preferred product failures/contraindications
  • Current bleeding pattern documentation
  • Prescriber medical necessity letter (if step therapy exception needed)

Submission & Follow-up

  • PA submitted electronically via CoverMyMeds or provider portal
  • Confirmation number recorded
  • Accredo enrollment initiated
  • Status check scheduled for day 3-4
  • Appeal materials prepared (in case of denial)

FAQ

How long does Cigna prior authorization take for Alprolix in Washington? Standard review takes 5 business days from complete submission. Expedited review for urgent cases takes 24 hours.

What if Alprolix is non-formulary on my Cigna plan? You can request a formulary exception by submitting a medical necessity letter explaining why preferred alternatives are inappropriate for your specific situation.

Can I request an expedited appeal in Washington? Yes, if your health could be in serious jeopardy. Expedited external reviews through Washington's IRO process provide decisions within 72 hours.

Does step therapy apply if I've tried other factor products outside Washington? Yes, documentation of previous trials from any location counts toward meeting step therapy requirements. Ensure your hematologist includes detailed records of what was tried, when, and why it failed.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna staff. External appeals are reviewed by independent medical experts assigned by Washington's Insurance Commissioner, and their decisions are binding on Cigna.

How much does Alprolix cost if approved? Annual costs vary by weight and dosing regimen. A 70 kg adult on weekly prophylaxis might use ~182,000 IU annually, with a wholesale cost around $708,000 before insurance coverage and manufacturer discounts.

What if my employer plan is self-funded? Self-funded plans may not be subject to Washington state laws, but many voluntarily follow state external review processes. Contact the U.S. Department of Labor for ERISA plan appeals if needed.

Can Counterforce Health help with my Alprolix appeal? Counterforce Health specializes in turning insurance denials into evidence-backed appeals for specialty medications like Alprolix, helping patients navigate complex payer requirements and clinical documentation needs.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult your healthcare provider for medical decisions and contact your insurance company or the Washington Office of the Insurance Commissioner for specific coverage questions. Coverage policies may vary by plan and can change over time.

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