By Counterforce Health Team in Arcalyst (rilonacept) —

How to Get Arcalyst (rilonacept) Covered by Cigna in Pennsylvania: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Arcalyst (rilonacept) Covered by Cigna in Pennsylvania

Fastest path to approval: Submit Cigna's prior authorization through CoverMyMeds with specialist attestation, diagnosis confirmation (CAPS, DIRA, or recurrent pericarditis), and documented prior therapy failures. If denied, you have 180 days for internal appeals, then 4 months to file Pennsylvania's independent external review, which overturns ~50% of denials. Start today: Verify your Cigna plan type (fully insured vs. self-funded) and download the current PA form from Express Scripts or CoverMyMeds portal.

Table of Contents

  1. Verify Your Plan and Find the Correct Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Electronic Filing
  4. Specialty Pharmacy Setup with Accredo
  5. Appeals Process: Internal and External Review
  6. Common Denial Reasons and Solutions
  7. Pennsylvania External Review Process
  8. Contact Information and Support Lines
  9. Costs and Patient Assistance Programs
  10. FAQ: Arcalyst (rilonacept) Coverage in Pennsylvania

I. Verify Your Plan and Find the Correct Forms

Before starting any prior authorization process, confirm whether your Cigna plan is fully insured or self-funded. This determines which appeals processes apply:

  • Fully insured plans (most individual/small group): Eligible for Pennsylvania's external review
  • Self-funded employer plans: Follow ERISA federal appeals process only

Contact your HR benefits office or check your Summary Plan Description to verify plan type. Pennsylvania's external review doesn't apply to Medicare, Medicaid, or self-funded employer plans.

Tip: If you're unsure about your plan type, call Cigna member services at 1-800-668-3813 with your member ID ready.

II. Prior Authorization Forms and Requirements

Coverage Requirements for Arcalyst (rilonacept)

Cigna requires prior authorization for Arcalyst across all FDA-approved indications. The medication must be prescribed by or in consultation with a specialist:

Indication Age Requirement Specialist Required Key Documentation
CAPS (Familial Cold Autoinflammatory Syndrome, Muckle-Wells Syndrome) ≥12 years Rheumatologist, geneticist, allergist/immunologist, or dermatologist Confirmed diagnosis, genetic testing results
DIRA (Deficiency of IL-1 Receptor Antagonist) Weight ≥10 kg (22 lbs) Rheumatologist, geneticist, dermatologist, or specialist IL1RN gene mutation confirmation, prior Kineret response
Recurrent Pericarditis ≥12 years Cardiologist or rheumatologist preferred ≥3 episodes in past year, failed standard therapy

Required Form Elements

When completing Cigna's PA form through CoverMyMeds, ensure you include:

Patient Information:

  • Full name, Cigna member ID, date of birth
  • Complete address and phone number
  • Diagnosis with ICD-10 codes
  • Weight (required for DIRA patients)

Prescriber Information:

  • Physician name, specialty, DEA/NPI/TIN numbers
  • Office contact information and signature
  • Attestation of accuracy for all provided information

Clinical Documentation:

  • Specific diagnosis confirmation (genetic testing for DIRA/CAPS)
  • Prior therapy history and outcomes
  • Current symptoms and disease activity markers
  • Proposed dosing schedule and administration plan

III. Submission Portals and Electronic Filing

Electronic Prior Authorization (Preferred Method)

Cigna strongly recommends electronic submission for faster processing:

  1. CoverMyMeds Portal: Primary platform for Cigna PA submissions
  2. SureScripts ePA: Integrated within most EHR systems
  3. EviCore - Pharmacy Drugs: For Express Scripts-managed specialty medications

Submission Best Practices

  • Submit during business hours (Monday-Friday, 8 AM-5 PM EST) for fastest review
  • Mark as "urgent" only if standard processing delays could jeopardize life, health, or function
  • Include all required attachments in initial submission to avoid delays
  • Save confirmation numbers and submission receipts
Note: Fax submissions to 1-866-873-8279 are discouraged due to slower processing times and privacy concerns.

IV. Specialty Pharmacy Setup with Accredo

For Cigna members with Express Scripts pharmacy benefits, Arcalyst typically requires dispensing through Accredo Specialty Pharmacy. This process runs parallel to prior authorization:

Dual Enrollment Process

  1. Manufacturer Enrollment: Complete Kiniksa OneConnect form and fax to 781-609-7826
  2. Accredo Setup: Call 1-877-622-3362 or enroll online after PA approval

Required Information for Accredo

  • Cigna member ID and Express Scripts information
  • Complete prescription from prescriber
  • Shipping address and preferred delivery schedule
  • Emergency contact information

Your assigned Patient Access Lead from Kiniksa OneConnect will coordinate between the manufacturer, Accredo, and your healthcare team throughout the process.

V. Appeals Process: Internal and External Review

Cigna Internal Appeals Timeline

Appeal Level Deadline to File Cigna Decision Time Required Documentation
First-Level Internal 180 days from denial 30 days (72 hours if urgent) Original denial letter, medical records, specialist letter
Second-Level Internal Per plan documents 30 days (72 hours if urgent) Additional clinical evidence, updated specialist attestation

Key Appeal Documentation

Medical Necessity Letter Checklist:

  • Confirmed diagnosis with supporting test results
  • Complete prior therapy history and specific reasons for failure/intolerance
  • Clinical rationale citing FDA labeling and peer-reviewed literature
  • Proposed monitoring plan and treatment goals
  • Specialist attestation of medical necessity
From our advocates: We've seen strong success when specialists directly address Cigna's specific denial reasons in their letters. For example, if denied for "lack of specialist consultation," include the specialist's credentials and detailed assessment. If denied for insufficient prior therapy, document specific medications tried, doses, duration, and reasons for discontinuation.

VI. Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Not prescribed by specialist Obtain consultation note or transfer care Specialist evaluation with credentials
Insufficient prior therapy Document failed treatments Pharmacy records, clinic notes showing failures
Diagnosis not confirmed Provide genetic testing or additional workup Lab results, imaging, specialist confirmation
Non-formulary medication Request formulary exception Medical necessity letter, alternative contraindications

Step Therapy Considerations

While Cigna doesn't specify step therapy requirements for Arcalyst, they may require documentation of failed conventional treatments:

  • CAPS/DIRA: Previous IL-1 inhibitor trials (especially Kineret for DIRA)
  • Recurrent Pericarditis: NSAIDs, colchicine, and corticosteroids

VII. Pennsylvania External Review Process

Pennsylvania's Independent External Review Program, launched in 2024, provides a powerful tool for overturning Cigna denials. The program has achieved approximately 50% success rate in its first year.

Eligibility Requirements

  • Completed Cigna's internal appeal process
  • Received "Final Adverse Benefit Determination" letter
  • Filing within 4 months of final denial date
  • Fully insured plan (not self-funded, Medicare, or Medicaid)

Filing Process

  1. Online Submission: Use Pennsylvania Insurance Department's external review portal
  2. Required Documents:
    • Final denial letter from Cigna
    • Insurance card copy
    • Complete medical records
    • Specialist letters addressing denial reasons

Timeline and Decision

Standard Review:

  • 45 days maximum for final decision
  • 15 days to submit additional evidence after IRO assignment
  • Binding decision on Cigna if coverage is approved

Expedited Review:

  • 72 hours for urgent cases requiring physician certification
  • 24-hour implementation if approved

VIII. Contact Information and Support Lines

Cigna Member Services

Pennsylvania Insurance Department

  • Consumer Services: Available through pa.gov
  • External Review: Online portal for filing appeals
  • Phone Support: Listed on PID consumer services pages

Manufacturer Support

  • Kiniksa OneConnect: 781-609-7826 (fax for enrollment)
  • Patient Access Lead: Assigned after enrollment for ongoing support

IX. Costs and Patient Assistance Programs

Financial Assistance Options

Manufacturer Support:

  • Kiniksa OneConnect provides benefit verification and PA assistance
  • Potential copay assistance programs (verify eligibility requirements)

Foundation Grants:

  • Patient advocacy organizations may offer grants for rare disease treatments
  • Income and diagnosis-based eligibility varies by program

State Resources:

  • Pennsylvania's expanded Medicaid coverage through Pennie marketplace
  • Consumer assistance through Pennsylvania Health Law Project

X. FAQ: Arcalyst (rilonacept) Coverage in Pennsylvania

Q: How long does Cigna prior authorization take for Arcalyst? A: Standard review takes up to 15 business days. Urgent requests are processed within 72 hours if delay could jeopardize health.

Q: What if Arcalyst is not on Cigna's formulary? A: Request a formulary exception with medical necessity documentation. Include specialist letter explaining why formulary alternatives are inappropriate.

Q: Can I get expedited appeals in Pennsylvania? A: Yes, both Cigna internal appeals and Pennsylvania external review offer expedited processing for urgent medical situations requiring physician certification.

Q: Does step therapy apply if I've tried treatments outside Pennsylvania? A: Yes, prior therapy documentation from any location is valid. Provide pharmacy records and clinic notes from previous providers.

Q: What happens if Pennsylvania external review approves coverage? A: Cigna must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during the appeal.

Q: How much does Arcalyst cost without insurance? A: Cash prices typically range several thousand dollars per 220mg kit, varying by pharmacy. Contact Kiniksa OneConnect for assistance programs.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements. For complex cases like Arcalyst approvals, we help identify denial reasons and draft appeals that align with payer-specific workflows and Pennsylvania's regulatory requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits, medical circumstances, and payer policies. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For questions about Pennsylvania insurance regulations, contact the Pennsylvania Insurance Department.

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