By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

How to Get Arikayce (Amikacin Liposome Inhalation) Covered by Cigna in Illinois: Complete Prior Authorization and Appeal Guide

Answer Box: Fast Track to Arikayce Coverage

Cigna requires prior authorization for Arikayce (amikacin liposome inhalation) through Accredo specialty pharmacy. To get approved in Illinois: (1) Your pulmonologist or infectious disease specialist submits PA documentation showing ≥6 months of failed MAC therapy with positive cultures, (2) Request goes through Express Scripts/EviCore portal or phone (1-800-882-4462), (3) If denied, you have 180 days for internal appeal, then 4 months for Illinois external review through the state Department of Insurance. Start today: Contact your prescriber to begin PA submission with required culture results and treatment history.

Table of Contents

What Drives Arikayce Costs with Cigna

Arikayce typically lands on Cigna's specialty tier (Tier 4 or 5), meaning higher copays and strict management controls. The drug costs approximately $1,500-$1,600 per 590mg vial, with treatment requiring daily dosing.

Key cost factors:

  • Prior authorization requirement: All Cigna plans require PA for refractory MAC lung disease
  • Specialty pharmacy mandate: Must use Accredo for coverage
  • Quantity limits: Typically 84 vials per 84 days initially
  • Limited population approval: FDA-approved only for specific refractory cases

Your out-of-pocket costs depend on your specific plan's specialty tier copay or coinsurance structure.

Benefit Investigation: Questions to Ask

Before starting the PA process, gather this information from Cigna:

Call Cigna Customer Service (number on your ID card):

  • "Is Arikayce on my formulary, and what tier?"
  • "What's my specialty drug copay or coinsurance?"
  • "Do I need to use Accredo specialty pharmacy?"
  • "What's my annual out-of-pocket maximum?"
  • "Are there quantity limits beyond the initial 84-day supply?"

Record this information:

  • Plan name and member ID
  • Specialty tier copay amount
  • Deductible remaining
  • Prior authorization requirements confirmed
  • Accredo phone number for your plan

Prior Authorization Requirements

Cigna's PA criteria align with FDA labeling for refractory MAC lung disease. All requirements must be met:

Clinical Criteria

  • Confirmed refractory MAC lung disease with ≥2 positive sputum cultures
  • Failed background therapy: ≥6 consecutive months of multidrug regimen (≥2 drugs)
  • Amikacin susceptibility: MAC isolate with MIC ≤64 mcg/mL per lab report
  • Specialist prescriber: Pulmonologist or infectious disease physician
  • Ongoing combination therapy: Used as add-on to continued multidrug regimen

Required Documentation

Your prescriber submits via Express Scripts portal or calls 1-800-882-4462:

  • Treatment history with dates and drug names
  • Sputum culture results showing positive MAC
  • Amikacin susceptibility testing (MIC values)
  • CT imaging supporting diagnosis
  • ICD-10 code A31.0 (infection due to other mycobacteria)
  • Prescriber attestation of medical necessity
Tip: The approval process typically takes 1-3 business days once complete documentation is received.

Assistance Programs and Cost Support

Manufacturer Support: inLighten Program

Insmed's inLighten Co-pay Savings Program helps commercially insured patients reduce out-of-pocket costs:

  • Eligibility: Commercial/private insurance (excludes Medicare, Medicaid)
  • Enrollment: Call 833-544-4800 (Monday-Friday, 8 AM-8 PM ET)
  • Process: Prescriber completes enrollment form; inLighten coordinates with specialty pharmacy
  • Benefits: Copay reduction (specific amounts determined during enrollment)

Additional Resources

  • Patient assistance foundations: Organizations like Good Days, Patient Access Network Foundation may provide grants for government-insured patients
  • Illinois Medicaid: If eligible, covers Arikayce through managed care organizations with PA

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to each plan's specific policies.

Appeals Process in Illinois

Illinois provides strong patient protections through the Health Carrier External Review Act. Here's your step-by-step path if Cigna denies coverage:

Internal Appeals (Required First Step)

Timeline: Submit within 180 days of denial Process:

  1. Call Cigna Customer Service to request internal appeal
  2. Submit written request with medical records
  3. Cigna acknowledges within 3 business days
  4. Decision within 15 business days (24 hours if expedited)

External Review Through Illinois DOI

If internal appeal fails, Illinois law guarantees independent review:

Eligibility: Denials for medical necessity, experimental treatment, or pre-existing conditions Timeline: Must request within 4 months of Cigna's final internal denial Process:

  1. Download form from Illinois Department of Insurance
  2. Submit complete application with medical records
  3. Independent Review Organization (IRO) assigned
  4. Decision within 45 days (24-72 hours if expedited)

Success rates: Illinois external reviews overturn approximately 52% of denials, though fewer than 3% of denied patients reach this stage.

When to Request Expedited Review

Request expedited processing if delay would:

  • Seriously jeopardize your health
  • Compromise your ability to regain maximum function
  • Subject you to severe pain that cannot be managed

Pharmacy Choice and Coordination

Accredo Specialty Pharmacy (Required)

Why Accredo: Cigna requires specialty drugs like Arikayce to go through Accredo for coverage. Retail pharmacies typically result in no coverage or significantly higher costs.

Setup process:

  1. After PA approval, prescriber sends prescription directly to Accredo
  2. Accredo calls you within 24-48 hours for insurance verification
  3. Cold-chain delivery scheduled (usually 2-3 business days)
  4. Lamira Nebulizer System provided with first shipment

Accredo benefits:

  • Integrated copay assistance processing
  • Clinical pharmacist support
  • Refill reminders and adherence monitoring
  • Coordination with inLighten program

Transfer from Retail Pharmacy

If you have an existing prescription elsewhere:

  1. Cancel refills at current pharmacy
  2. Request new prescription sent directly to Accredo (avoid transfer requests)
  3. Contact inLighten support (833-544-4800) for transition assistance

Renewal Planning

Reauthorization Requirements

Cigna typically approves Arikayce for 6-12 months initially. For renewal:

Clinical updates needed:

  • Recent sputum culture results
  • Treatment response documentation
  • Continued specialist oversight
  • Updated lab values and imaging if relevant

Timeline: Submit reauthorization 30 days before current approval expires to avoid treatment gaps.

Annual Plan Changes

January considerations:

  • Formulary changes may affect tier placement
  • Copay amounts can change with new plan year
  • Prior authorization criteria may be updated
  • Specialty pharmacy networks can change

Review your plan documents each January and contact Cigna to confirm continued coverage terms.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Insufficient treatment duration Document exact dates of 6+ month regimen with pharmacy records
Missing culture results Submit lab reports showing positive MAC cultures post-treatment
Lack of specialist involvement Ensure pulmonologist or ID specialist is prescriber of record
No amikacin susceptibility testing Request lab to perform MIC testing and submit results
Off-label use concern Emphasize FDA-approved indication for refractory MAC lung disease
Step therapy required Document failure/intolerance of required first-line agents

Scripts for Key Conversations

Calling Cigna Customer Service

"I need to check prior authorization status for Arikayce, spelled A-R-I-K-A-Y-C-E, generic name amikacin liposome inhalation suspension. My prescriber submitted a request on [date]. Can you tell me the status and any additional requirements?"

Requesting Expedited Appeal

"I'm requesting an expedited appeal for Arikayce denial because my refractory MAC lung disease is worsening without treatment, and delay could seriously jeopardize my health. I need the 24-hour expedited timeline."

FAQ

How long does Cigna prior authorization take for Arikayce? Typically 1-3 business days with complete documentation. Incomplete submissions may take 5-7 days.

What if Arikayce isn't on my Cigna formulary? Request a formulary exception through your prescriber, providing medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I use a retail pharmacy instead of Accredo? Most Cigna plans require Accredo for specialty drug coverage. Using retail typically results in no coverage or significantly higher out-of-pocket costs.

Does Illinois have special protections for rare disease medications? Yes, Illinois' Health Carrier External Review Act provides independent physician review of medical necessity denials, with a 52% overturn rate.

What happens if I miss the appeal deadline? Internal appeals must be filed within 180 days; external reviews within 4 months of final internal denial. Missing deadlines typically eliminates appeal rights for that denial.

How much does Arikayce cost with Cigna coverage? Costs depend on your specific plan's specialty tier. With commercial insurance and inLighten copay assistance, many patients pay $0-$50 per month.

Counterforce Health helps patients navigate complex insurance appeals by analyzing denial letters and crafting targeted, evidence-backed responses that align with each plan's specific policies. Their platform identifies the exact denial basis and builds point-by-point rebuttals using the right clinical evidence and procedural requirements.

Need additional help?

  • Illinois Department of Insurance: insurance.illinois.gov
  • Illinois Attorney General Health Helpline: 1-877-305-5145
  • Cigna Customer Service: Number on your member ID card

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

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