By Counterforce Health Team in Berinert (C1-esterase inhibitor, IV) —

How to Get Berinert (C1-Esterase Inhibitor) Covered by Cigna in Washington: Appeals Guide with Forms and Timelines

Quick Answer: Getting Berinert Covered by Cigna in Washington

Berinert requires prior authorization from Cigna for all uses. The fastest path to approval: 1) Have your allergist/immunologist submit a PA request with documented HAE type I/II diagnosis, prior treatment history, and weight-based dosing rationale. 2) If denied, file an internal appeal within 180 days with clinical evidence. 3) Request external review through Washington's Independent Review Organization if internal appeal fails. Start today: Call Cigna at 1-800-882-4462 to request PA forms or access the member portal at myCigna.com.

Table of Contents

Plan Types & Coverage Implications

Cigna offers multiple plan types in Washington, each with different coverage pathways for Berinert:

Commercial Plans (HMO/PPO/EPO): Most require prior authorization through Cigna's medical management team. PPO plans typically offer more flexibility in specialist access, while HMO plans may require referrals to allergists/immunologists.

Medicare Advantage: Berinert coverage follows Medicare Part B guidelines for acute HAE attacks, with additional Cigna-specific prior authorization requirements for prophylactic use.

Medicaid (Apple Health): Coverage varies by managed care organization. Cigna's Medicaid plans in Washington follow state guidelines but maintain their own utilization management protocols.

Note: Self-funded employer plans may have different appeal rights. Contact your HR department to confirm whether Washington state external review applies to your plan.

Formulary Status & Tier Placement

Berinert typically appears on Cigna's specialty tier with the following characteristics:

  • Prior Authorization Required: All indications (acute treatment and prophylaxis)
  • Specialty Pharmacy Requirement: Must be dispensed through Accredo or approved specialty pharmacy
  • Quantity Limits: Maximum 4 attacks per 28 days for acute treatment; prophylaxis limited to 1,000 units IV every 3-4 days

Alternative Agents: Cigna's formulary includes other HAE treatments like Icatibant (Firazyr), Ruconest, and newer options like Takhzyro. Step therapy may require trying first-line prophylactic agents before Berinert approval for prevention.

Prior Authorization Requirements

Medical Necessity Criteria

According to Cigna's HAE coverage policy, approval requires:

Diagnostic Documentation:

  • Laboratory-confirmed HAE type I or type II diagnosis
  • Low functional C1-INH protein levels (less than 50% of normal)
  • Below-normal serum C4 levels

Prescriber Requirements:

  • Prescription by or consultation with allergist/immunologist or HAE specialist
  • Documentation of patient's attack history and severity

Dosing Justification:

  • Weight-based dosing calculation (20 units/kg per attack)
  • Clinical rationale for quantities exceeding standard limits

Submission Process

  1. Access Forms: Log into the Cigna provider portal or call 1-800-882-4462
  2. Required Documentation:
    • Completed prior authorization form
    • Clinical notes documenting HAE diagnosis
    • Laboratory results (C1-INH levels, C4 levels)
    • Prior treatment history and outcomes
  3. Timeline: Standard review takes 15 business days; expedited review available for urgent cases (72 hours)

Specialty Pharmacy Setup

Cigna routes most specialty medications, including Berinert, through Accredo Specialty Pharmacy.

Enrollment Steps

  1. Call Accredo: 877-826-7657 (Monday-Friday 7:00 am-10:00 pm CST)
  2. Timing: Contact approximately two weeks before your next refill
  3. Required Information:
    • Cigna Healthcare ID card
    • Prescriber contact information
    • Current prescription details

Account Management

Once enrolled, manage your specialty medication through:

  • myCigna App/Website: Access via Prescriptions tab
  • Accredo.com: Create account using your Rx number

Accredo provides 24/7 access to specialty-trained pharmacists and handles temperature-controlled shipping at no extra cost.

Common Denial Reasons & Solutions

Denial Reason Documentation to Include Where to Find It
Missing HAE diagnosis Lab results showing low C1-INH and C4 levels Allergist/immunologist records
Prophylaxis not indicated Clinical notes documenting attack frequency/severity Treatment history from specialist
Quantity limits exceeded Weight calculation and attack pattern documentation Prescriber notes with dosing rationale
Site of care restrictions Medical justification for infusion location Clinic assessment of patient needs

Clinician Corner: Medical Necessity Letter Checklist

When preparing appeals, include:

  • Problem Statement: Document HAE type I/II with specific lab values
  • Prior Treatments: Detail previous therapies tried, including dates and outcomes
  • Clinical Rationale: Reference FDA labeling and HAE treatment guidelines
  • Dosing Justification: Weight-based calculations (20 units/kg per attack)
  • Monitoring Plan: Follow-up schedule and safety assessments

Appeals Process in Washington

Washington state provides robust protections for patients facing insurance denials through a two-tier system.

Internal Appeals

Timeline: 180 days from denial date to file How to File:

Review Timeline:

  • Standard review: 30 days
  • Expedited review: 72 hours (if health could be seriously jeopardized)

External Review (Independent Review Organization)

If your internal appeal is denied, Washington law guarantees access to an independent review.

How It Works:

  1. Request Review: File within 180 days of final internal denial
  2. Assignment: Washington Office of Insurance Commissioner assigns an IRO from their certified registry
  3. Review Process: IRO panel of appropriate specialists reviews medical necessity
  4. Timeline: 30 days for standard review; 72 hours for expedited
  5. Cost: Free to patients (insurer pays all fees)

Outcome: IRO decisions are binding on the insurer. If overturned, Cigna must provide coverage.

From our advocates: We've seen many HAE patients successfully overturn initial denials by providing comprehensive lab documentation and specialist letters. The key is demonstrating that the denial contradicts established clinical guidelines—something Washington's independent reviewers are well-equipped to evaluate.

Cost Considerations

Out-of-Pocket Expenses

Berinert costs can reach five figures per vial without insurance coverage. With Cigna coverage:

  • Specialty tier copay/coinsurance applies (verify with your specific plan)
  • Deductible may apply depending on plan structure
  • Out-of-pocket maximum provides annual cost protection

Financial Assistance Options

  • CSL Behring Patient Assistance: Berinert patient support program offers copay assistance and free drug programs
  • Washington State Programs: Apple Health (Medicaid) for eligible residents
  • Foundation Grants: National Organization for Rare Disorders (NORD) and other rare disease foundations

When to Escalate

Contact the Washington Office of Insurance Commissioner if:

  • Cigna fails to meet appeal deadlines
  • You suspect improper denial practices
  • The external review process isn't working properly

Washington OIC Consumer Advocacy: 1-800-562-6900 Website: insurance.wa.gov

The OIC provides free assistance with appeals and can investigate insurer practices that violate Washington law.

FAQ

How long does Cigna prior authorization take for Berinert in Washington? Standard review takes 15 business days. Expedited review (for urgent cases) takes 72 hours. Appeal reviews follow different timelines: 30 days for internal appeals, 30 days for external review.

What if Berinert is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating medical necessity. This requires clinical documentation showing why formulary alternatives are inappropriate for your case.

Can I request an expedited appeal in Washington? Yes, if your health could be seriously jeopardized by delays. Both internal and external appeals offer expedited pathways with 72-hour decision timelines.

Does step therapy apply if I've failed other HAE medications outside Washington? Medical records from any state showing prior treatment failures should satisfy step therapy requirements. Ensure your prescriber includes comprehensive treatment history in the PA request.

What happens if my employer plan is self-funded? Self-funded plans may not be subject to Washington state external review. Contact your HR department to understand your appeal rights, which may fall under federal ERISA protections instead.

How do I know if my Cigna plan covers home infusion for Berinert? Check your plan's coverage of home infusion services. Most Cigna plans cover home infusion when medically appropriate and cost-effective compared to outpatient facilities.

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 aligned to the insurer's own rules, pulling the right clinical evidence and meeting all procedural requirements. Learn more about our appeals platform.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may vary by plan type and can change. Always verify current requirements with Cigna directly and consult with your healthcare provider regarding treatment decisions. For personalized assistance with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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