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

How to Get Arikayce (Amikacin Liposome Inhalation) Covered by Cigna in Washington: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Arikayce Covered by Cigna in Washington

Cigna requires prior authorization for Arikayce (amikacin liposome inhalation) with strict criteria: adult MAC lung disease, documented failure after ≥6 months of guideline-based multidrug therapy, and prescription by a pulmonologist or infectious disease specialist. If denied, you have 180 days to appeal internally, followed by external review through Washington's Independent Review Organization. First step today: Have your specialist complete Cigna's PA request with detailed treatment history, sputum culture results, and medical necessity documentation. Contact inLighten Patient Support at 833-544-4800 for assistance with benefits verification and potential copay support.

Table of Contents

  1. What Drives Arikayce Costs with Cigna
  2. Benefit Investigation: What to Ask Cigna
  3. Prior Authorization Requirements
  4. Assistance Programs and Cost-Saving Options
  5. Appeals Process in Washington
  6. Pharmacy Choice: Accredo vs. Retail
  7. When to Request Formulary Exceptions
  8. Scripts and Templates
  9. FAQ

What Drives Arikayce Costs with Cigna

Arikayce typically costs $1,500-$1,600 per 590mg vial, making it one of the most expensive inhaled medications. Your out-of-pocket costs depend on several factors:

Formulary Tier Placement: Cigna places Arikayce on specialty tiers with coinsurance (typically 20-40%) rather than flat copays. This means you pay a percentage of the drug's cost up to your plan's maximum.

Specialty Pharmacy Requirement: Most Cigna plans require specialty drugs like Arikayce to be dispensed through Accredo Specialty Pharmacy for coverage. Using retail pharmacies may result in higher costs or no coverage.

Utilization Management: Cigna applies prior authorization, quantity limits, and step therapy requirements to control costs and ensure appropriate use.

Benefit Investigation: What to Ask Cigna

Before starting treatment, gather this information by calling the number on your insurance card:

Essential Questions for Cigna

  • "Is Arikayce covered under my pharmacy or medical benefit?"
  • "What tier is Arikayce on, and what's my coinsurance percentage?"
  • "Do I need to use Accredo, or can I use retail pharmacies?"
  • "What's my specialty drug deductible and out-of-pocket maximum?"
  • "Is prior authorization required, and where do I submit it?"

Information to Record

Create a log with:

  • Representative name and reference number
  • Date and time of call
  • Specific answers about coverage, costs, and requirements
  • Any authorization numbers or case references

Prior Authorization Requirements

Cigna's coverage policy for Arikayce requires meeting all these criteria:

Medical Necessity Criteria

Requirement Documentation Needed ICD-10 Code
Adult MAC lung disease Clinical, radiographic, microbiologic evidence per ATS/IDSA guidelines A31.0
Refractory disease ≥6 months documented multidrug therapy failure -
Amikacin susceptibility Lab report showing MIC ≤64 mcg/mL -
Combination therapy Background regimen (macrolide + ethambutol ± rifamycin) -
Specialist oversight Prescription by pulmonologist or ID specialist -

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete treatment history with dates, medications, and outcomes
    • Sputum culture results showing persistent MAC positivity
    • Chest imaging (CT) showing MAC lung disease
    • Timeline: 1-2 days
  2. Complete PA Request (Prescriber)
    • Submit via Cigna provider portal or fax
    • Include medical necessity letter addressing all criteria
    • Timeline: Same day submission
  3. Benefits Verification (Patient)
  4. Follow Up (Clinic/Patient)
    • Track PA status through Cigna portal
    • Respond promptly to any requests for additional information
    • Timeline: 5-7 business days for determination
Clinician Corner: Your medical necessity letter should address each denial risk point-by-point. Reference the 2020 ATS/ERS/ESCMID/IDSA guidelines for MAC, document specific treatment failures with dates and reasons, and explain why Arikayce is the appropriate next step for this patient's refractory MAC lung disease.

Assistance Programs and Cost-Saving Options

Manufacturer Support: inLighten Program

Insmed's inLighten Patient Support provides:

  • Commercial Insurance Copay Assistance: Eligible patients may pay as little as $0 per month (program maximum applies)
  • Benefits Investigation: Help with prior authorization and appeals
  • Clinical Support: Respiratory educator for nebulizer training
  • Eligibility: Adults with commercial insurance, U.S. residents, valid Arikayce prescription
Note: Medicare and Medicaid patients cannot use manufacturer copay cards but may qualify for other support through the program.

Independent Foundation Support

  • The Assistance Fund (TAF): NTM Info & Research refers patients to TAF for income-based copay assistance
  • Disease-Specific Grants: Contact NTM Info & Research for current MAC/NTM patient assistance programs

State Programs

Washington residents may qualify for:

  • Apple Health (Medicaid) if income-eligible
  • Washington Healthplanfinder premium tax credits for marketplace plans

Appeals Process in Washington

If Cigna denies your Arikayce request, Washington provides strong consumer protections:

Internal Appeals

Timeline: 180 days from denial date to file first-level appeal

Required Documentation:

  • Original denial letter with reference numbers
  • Complete medical records and treatment history
  • Point-by-point rebuttal addressing each denial reason
  • Updated clinical information if available

External Review in Washington

Washington's Independent Review Organization (IRO) process provides final appeal rights:

Eligibility: Available after completing internal appeals Timeline:

  • Request deadline: 180 days from final internal denial
  • Decision timeline: 30 days (72 hours for expedited)
  • Cost: Free to patients

How to Request:

  1. Contact Washington Insurance Commissioner at 1-800-562-6900
  2. Submit request through your insurer or directly to OIC
  3. IRO assigned automatically from state registry
From our advocates: We've seen Washington patients successfully overturn Arikayce denials through external review when the initial denial was based on incomplete documentation of treatment failure. The key was providing a detailed timeline showing exactly which medications were tried, for how long, and why they failed or weren't tolerated. This isn't guaranteed, but thorough documentation often makes the difference.

Pharmacy Choice: Accredo vs. Retail

Accredo Specialty Pharmacy (Preferred)

Most Cigna plans require Arikayce to be dispensed through Accredo for coverage:

Benefits:

  • Guaranteed in-network processing
  • Integrated with Cigna's prior authorization system
  • Manufacturer copay assistance coordination
  • Clinical support and adherence monitoring

Process:

  • Prescriber sends prescription electronically to Accredo
  • Accredo contacts patient for delivery coordination
  • Home delivery with cold-chain shipping

Retail Pharmacy Considerations

Using retail pharmacies may result in:

  • Higher out-of-pocket costs or no coverage
  • Limited availability due to specialty distribution
  • Separate copay assistance enrollment needed

Verify First: Check with Cigna whether retail fills are covered for your specific plan before switching from Accredo.

When to Request Formulary Exceptions

If Arikayce is non-formulary or requires step therapy you cannot complete, request a formulary exception:

Exception Types Available

  • Non-formulary drug coverage
  • Step therapy override
  • Quantity limit increase
  • Prior authorization waiver

Medical Justification Required

Your physician must certify that:

  • Previous formulary drugs were ineffective or caused adverse effects
  • Required step therapy drugs are expected to be ineffective based on clinical characteristics
  • The requested drug is medically appropriate and in your best interest

Scripts and Templates

Patient Phone Script for Cigna

"I'm calling about prior authorization for Arikayce, amikacin liposome inhalation suspension. My doctor prescribed this for MAC lung disease that hasn't responded to six months of standard treatment. Can you tell me the status of PA request [reference number] and what additional information you need?"

Clinic Staff Script for Peer-to-Peer

"I'm requesting a peer-to-peer review for [patient name] regarding Arikayce denial. This patient has refractory MAC lung disease documented by persistent positive cultures after six months of guideline-based multidrug therapy. The denial appears to be based on [specific reason]. When can we schedule the peer-to-peer with a pulmonologist or infectious disease specialist?"

FAQ

How long does Cigna prior authorization take for Arikayce in Washington? Standard PA decisions are typically made within 5-7 business days. Expedited reviews (for urgent medical needs) must be completed within 24-72 hours.

What if Arikayce is non-formulary on my Cigna plan? Request a formulary exception with medical justification. Your doctor must document why formulary alternatives are inappropriate for your specific case.

Can I get expedited appeals if my condition is worsening? Yes, Washington allows expedited external review (72 hours) if delay could seriously jeopardize your health. Request this when filing your appeal.

Does step therapy apply if I failed treatments outside Washington? Treatment history from other states counts toward step therapy requirements. Provide complete documentation of prior therapies and outcomes.

What's the difference between medical necessity and formulary exceptions? Medical necessity focuses on whether the drug is appropriate for your condition. Formulary exceptions address coverage when the drug isn't on your plan's preferred list.

How do I track my appeal status? Use Cigna's member portal or call the number on your ID card with your reference number. Keep a log of all communications and deadlines.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn 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 documentation and payer-specific evidence, helping you navigate complex prior authorization and appeals processes more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific 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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