By Counterforce Health Team in Amondys 45 (casimersen) —

How to Get Amondys 45 (casimersen) Covered by Cigna in Washington: Complete Forms, Appeals & Genetic Testing Guide

Quick Answer: Getting Amondys 45 (casimersen) Covered by Cigna in Washington

Eligibility: Cigna covers Amondys 45 for DMD patients with confirmed exon 45-amenable mutations through prior authorization. Fastest path: Have your neuromuscular specialist submit genetic test results plus clinical documentation to Cigna's specialty pharmacy team. Start today: Call Cigna at the number on your ID card to confirm Accredo is your required specialty pharmacy and request the current prior authorization form. If denied, Washington's external review process gives you strong appeal rights through an Independent Review Organization (IRO).

Table of Contents

  1. Verify Your Plan & Find Forms
  2. Required Genetic Testing & Documentation
  3. Prior Authorization Forms & Submission
  4. Specialty Pharmacy Setup (Accredo)
  5. Appeals Process: Internal & External Review
  6. Support Resources & Contact Information
  7. Common Denial Reasons & Solutions
  8. Timeline & Next Steps

Verify Your Plan & Find Forms

Before starting, confirm your Cigna plan covers specialty medications through Accredo and locate the current prior authorization requirements.

Step 1: Check Your Coverage

  • Call the member services number on your Cigna ID card
  • Ask specifically: "Is Amondys 45 covered on my formulary, and is prior authorization required?"
  • Confirm Accredo is your mandated specialty pharmacy for this medication
  • Request they email or mail you the current prior authorization form

Step 2: Understand Your Plan Type

Washington residents may have:

  • Fully insured Cigna plans: Subject to Washington state appeal protections
  • Self-funded employer plans: May follow federal appeal rules instead
  • Ask your HR department or Cigna which type you have, as this affects your appeal rights

Required Genetic Testing & Documentation

Amondys 45 is only approved for DMD patients whose specific genetic mutation is amenable to exon 45 skipping. Insurance approval hinges on proving this genetic eligibility.

Genetic Testing Requirements

Essential documentation:

  • Comprehensive DMD gene analysis (not just muscle biopsy)
  • Lab report clearly stating the mutation is "amenable to exon 45 skipping"
  • Confirmation that exon 45 is present in the patient's dystrophin gene
Note: Genetic testing must identify specific deletion/duplication patterns where skipping exon 45 would restore the reading frame.

Clinical Documentation Checklist

Your neuromuscular specialist should provide:

  • ✅ DMD diagnosis with ICD-10 code (G71.01)
  • ✅ Current functional status (North Star Ambulatory Assessment, 6-minute walk test)
  • ✅ Weight and dosing calculations
  • ✅ Baseline cardiac and pulmonary function
  • ✅ Treatment goals and monitoring plan

Prior Authorization Forms & Submission

Required Forms

  1. Cigna Pharmacy Prior Authorization Form - Download the most current version from Cigna's provider forms page
  2. Accredo Prescription & Enrollment Form - Available on Accredo's referral forms page

Submission Process

By Fax (most common):

  • Complete all sections of the PA form
  • Attach genetic test results and clinical notes
  • Fax to the number listed on the form for your specific plan type
  • Keep fax confirmation receipts

Online Portal:

  • Providers can submit through Cigna's online portal
  • Upload all supporting documents as PDFs
  • Track submission status online
Tip: Include a cover sheet listing all attached documents to ensure nothing gets lost in processing.

Specialty Pharmacy Setup (Accredo)

Cigna requires most specialty medications, including Amondys 45, to be dispensed through Accredo. Here's how to get set up:

Enrollment Steps

  1. Prescriber submits referral: Your doctor completes the Accredo enrollment form
  2. Benefits verification: Accredo confirms your Cigna coverage and PA status
  3. Patient consent: You'll need to authorize Accredo to access your medical records
  4. Delivery setup: Choose home delivery or clinic administration

What to Expect

  • Timeline: 5-10 business days after PA approval
  • First shipment: Includes medication, supplies, and injection training materials
  • Ongoing: Automatic refills with clinical check-ins

For questions, call Accredo at 1-800-803-2523.

Appeals Process: Internal & External Review

If Cigna denies your prior authorization, Washington provides strong appeal rights.

Internal Appeals (First Step)

Timeline: File within 180 days of denial Process:

  1. Submit written appeal to address on denial letter
  2. Include additional clinical evidence
  3. Request peer-to-peer review with medical director
  4. Standard decision: 30 days; expedited: 72 hours

External Review (Washington IRO Process)

If internal appeals fail, Washington law provides independent review:

Who qualifies: Patients with fully insured Cigna plans in Washington Timeline: Request within 60 days of final internal denial Process: Independent medical experts review your case Outcome: Binding decision on Cigna if approved

Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 for free help with external reviews.

Support Resources & Contact Information

Primary Contacts

Resource Phone Purpose
Cigna Member Services Number on your ID card Coverage questions, PA status
Accredo Specialty Pharmacy 1-800-803-2523 Enrollment, shipments, clinical support
Washington Insurance Commissioner 1-800-562-6900 Appeal help, consumer protection
Sarepta Patient Services 1-888-SAREPTA Manufacturer support, financial assistance

Online Resources

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient genetic testing Submit comprehensive DMD gene analysis Lab report confirming exon 45-amenable mutation
Missing clinical criteria Provide functional assessments North Star scores, 6-minute walk test, specialist letter
Step therapy not met Document contraindications to alternatives Clinical notes explaining why steroids/other DMD drugs aren't appropriate
Site of care issues Clarify infusion location Administration plan from certified infusion center
From our advocates: We've seen cases where initial denials were overturned simply by submitting a more detailed genetic report that explicitly stated "amenable to exon 45 skipping." The key is ensuring your lab uses that exact language rather than general DMD mutation findings.

Timeline & Next Steps

Expected Timeline

  • PA submission to decision: 5-10 business days
  • Appeal decision: 30 days (standard) or 72 hours (expedited)
  • External review: 20-30 days in Washington
  • First shipment: 5-10 days after approval

Your Next Steps Today

  1. Call Cigna to confirm coverage and get PA forms
  2. Schedule genetic counseling if testing isn't complete
  3. Contact your neuromuscular specialist to begin PA paperwork
  4. Gather clinical records from the past year
  5. Research financial assistance through Sarepta's patient program

If You Need Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Amondys 45. Our platform analyzes denial letters, identifies specific coverage gaps, and helps clinicians craft evidence-based appeals that align with each payer's requirements. We work with patients, specialty pharmacies, and clinicians to navigate the prior authorization process and improve approval rates for rare disease treatments.

For more guidance on specialty medication appeals, visit CounterforceHealth.org.

Frequently Asked Questions

How long does Cigna prior authorization take for Amondys 45? Standard PA decisions typically take 5-10 business days once all documentation is submitted. Expedited reviews for urgent cases can be completed in 24-72 hours.

What if Amondys 45 isn't on Cigna's formulary? You can request a formulary exception by having your prescriber document medical necessity and why covered alternatives aren't appropriate. Use Cigna's pharmacy formulary exception form.

Can I get an expedited appeal in Washington? Yes, if delay could seriously jeopardize your health. Both Cigna's internal appeals and Washington's external review process offer expedited timelines (72 hours for internal, 72 hours for external).

Does genetic testing have to be recent? Most insurers accept genetic testing done at any time, as DMD mutations don't change. However, clinical assessments (functional tests, cardiac/pulmonary status) should be recent (typically within 6-12 months).

What if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Washington state appeal protections. However, they still must provide internal appeals and often voluntarily offer external review. Contact the U.S. Department of Labor at 1-866-444-3272 for ERISA plan appeals help.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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