By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

How to Get Breyanzi (lisocabtagene maraleucel) Covered by Cigna in Illinois: Complete Guide to Prior Authorization, Appeals, and State Resources

Answer Box: Getting Breyanzi Covered by Cigna in Illinois

Fastest path to approval: Submit your prior authorization through CoverMyMeds or ExpressPAth with complete medical documentation showing refractory large B-cell lymphoma or CLL/SLL with transformation. First step today: Verify your plan covers specialty drugs through Express Scripts/Accredo, then gather pathology reports, treatment history, and molecular testing results. Illinois residents have strong appeal rights with 4-month external review windows and free independent physician reviewers through the Illinois Department of Insurance.

Table of Contents

Verify Your Plan & Find the Right Forms

Before starting your Breyanzi prior authorization, confirm your Cigna plan covers specialty medications through Express Scripts or Accredo. Look for these details on your member ID card:

Coverage Verification Steps:

  1. Check your ID card for specialty pharmacy information (usually mentions Express Scripts or Accredo)
  2. Call Cigna Member Services at 1-800-997-1654 to confirm coverage
  3. Review your plan documents for specialty drug benefits and copay structure
  4. Verify your provider is credentialed for CAR-T therapy administration
Note: Cigna typically manages high-cost specialty drugs like Breyanzi through prior authorization and quantity limits, even when covered.

Required Prior Authorization Forms

Cigna requires specific documentation for Breyanzi approval. The key forms and requirements include:

Essential Documentation:

  • Prior Authorization Request Form (available through portals below)
  • Medical necessity letter from your oncologist
  • Pathology reports confirming eligible diagnosis
  • Treatment history showing prior therapy failures
  • Molecular testing results (especially for CLL/SLL cases)

Coverage Criteria for 2024-2025: According to Cigna's coverage policy, Breyanzi is covered for:

  • Large B-cell lymphoma (LBCL): Including DLBCL, high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B
  • CLL/SLL with transformation: Must show histologic transformation to DLBCL plus del(17p)/TP53 mutation, chemotherapy-refractory status, or inability to tolerate chemoimmunotherapy

Required CPT Codes:

  • 2024: 0537T, 0538T, 0539T, 0540T
  • Starting January 1, 2025: 38225, 38226, 38227, 38228

Electronic Submission Portals

Electronic submission is the fastest route to approval. Use these verified portals:

Portal Access Best For
CoverMyMeds Online portal All Cigna/Express Scripts PA requests
ExpressPAth Online portal Express Scripts PA and renewals
MyAccredoPatients Prescriber login Accredo referrals and PA submissions
Surescripts/EHR Integrated systems Real-time ePA through your clinic's EHR

Submission Tips:

  • Upload all supporting documents in a single submission
  • Use clear file names (e.g., "Smith_Pathology_Report_2024.pdf")
  • Include cover letter summarizing medical necessity
  • Track submission status through the portal

Fax Numbers & Mail Addresses

When electronic submission isn't possible, use these verified contact methods:

Primary Fax Numbers:

  • General Prior Authorization: 877-815-4827
  • Accredo Physician Services: Use portal or call 844-516-3319 for fax instructions
  • Appeals (if needed): 877-815-4827 (or 877-804-1679 for "G" ID card holders)

Mailing Address: Use the address provided in your specific prior authorization form or contact Cigna at 1-800-244-6224 for current mailing instructions.

Tip: Always include a cover sheet with patient name, Cigna ID number, prescriber information, and urgency level.

Specialty Pharmacy Setup

Breyanzi requires specialty pharmacy coordination through Accredo (Cigna's specialty pharmacy partner):

Setup Process:

  1. Provider initiates referral to Accredo through MyAccredoPatients portal
  2. Patient enrollment with Accredo (they'll contact you directly)
  3. Insurance verification and prior authorization coordination
  4. Treatment center coordination for infusion scheduling
  5. Patient education and support services enrollment

Accredo Contact Information:

  • Physician Services: 844-516-3319
  • Patient Services: Contact number provided during enrollment
  • Portal: MyAccredoPatients for providers

Member & Provider Support Lines

Keep these numbers handy throughout your approval process:

Cigna Member Services:

  • 24/7 Customer Service: 1-800-997-1654
  • Provider Services: 1-800-244-6224
  • Specialty Pharmacy: 1-800-351-3606

What to Ask When You Call:

  • Current prior authorization status
  • Required documentation checklist
  • Timeline for decision
  • Appeal options if denied
  • Case management services availability

Illinois State Resources & Appeals

Illinois provides robust protection for patients facing insurance denials:

Illinois Department of Insurance:

  • Consumer Hotline: 877-527-9431
  • External Review: Free independent physician review after internal appeals
  • Timeline: 4 months to request external review after final denial

Illinois Attorney General Health Care Bureau:

  • Helpline: 877-305-5145
  • Services: Complaint assistance, informal insurer intervention, unfair practice investigations

External Review Process:

  1. Complete Cigna's internal appeal first (required)
  2. File external review request within 4 months of final denial
  3. Independent Review Organization (IRO) assigned within 1 business day
  4. Decision timeline: 45 days standard, 72 hours for expedited cases
  5. Binding decision: Cigna must comply if overturned

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix Required Documentation
Not meeting line of therapy Provide detailed treatment history Prior therapy records, dates, outcomes
Insufficient histology documentation Submit complete pathology reports Pathology with specific LBCL subtype
Missing molecular testing (CLL/SLL) Order and submit genetic testing del(17p)/TP53 mutation results
Center not credentialed Verify treatment facility certification CAR-T center accreditation documents
"Not medically necessary" Strengthen clinical rationale Guidelines citations, peer-reviewed studies

Medical Necessity Documentation

Your oncologist's medical necessity letter should include:

Required Elements:

  • Specific diagnosis with ICD-10 codes
  • Prior treatment history with dates, drugs, and outcomes
  • Current disease status and progression evidence
  • Clinical rationale for Breyanzi over alternatives
  • Treatment goals and expected outcomes
  • Monitoring plan and safety considerations

Supporting Evidence:

  • FDA labeling for approved indications
  • NCCN Guidelines or other specialty society recommendations
  • Peer-reviewed studies supporting use in your specific case
  • Contraindications to alternative therapies

Appeals Timeline for Illinois

Understanding deadlines is crucial for successful appeals:

Internal Appeal Process:

  • Filing deadline: 180 days from denial
  • Cigna response time: 15 business days (standard), 24 hours (expedited)
  • Required: Complete before external review

External Review Process:

  • Filing deadline: 4 months from final internal appeal denial
  • IRO assignment: 1 business day
  • Decision timeline: 45 days standard, 72 hours expedited
  • Cost: Free to patients (Illinois pays IRO fees)
Critical: Illinois has a shorter external review window than many states—don't wait to file your request.

FAQ

How long does Cigna prior authorization take for Breyanzi in Illinois? Standard review takes 5 business days; expedited review (for urgent cases) takes 24-72 hours. Electronic submissions through CoverMyMeds typically process faster than fax submissions.

What if Breyanzi isn't on Cigna's formulary? You can request a formulary exception through the same prior authorization process. Your oncologist will need to provide strong clinical justification for why covered alternatives aren't appropriate.

Can I appeal a Cigna denial while continuing treatment? Illinois law allows expedited appeals for urgent medical situations. If delay would seriously jeopardize your health, request expedited review and contact the Illinois Department of Insurance for assistance.

Does step therapy apply to CAR-T therapies like Breyanzi? Cigna's policy requires documentation of prior therapy failures, but this aligns with FDA-approved indications rather than arbitrary step therapy. Ensure your treatment history clearly shows refractory disease or intolerance to prior lines.

What happens if I miss an appeal deadline in Illinois? Missing the 180-day internal appeal deadline can forfeit your right to external review. However, Illinois law may provide exceptions for "good cause" delays. Contact the Illinois Department of Insurance immediately if you've missed a deadline.

How much will Breyanzi cost with Cigna coverage? Costs vary by plan, but expect specialty drug copays ranging from hundreds to thousands of dollars per treatment. Bristol Myers Squibb offers patient assistance programs—ask your treatment team about copay support options.

Getting personalized help with your Breyanzi appeal: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with your insurer's specific requirements, pulling the right medical evidence and citations to strengthen your case. For complex CAR-T therapy appeals like Breyanzi, having expert support can make the difference between approval and denial.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance representative. Coverage decisions depend on your specific plan terms and clinical circumstances. Always verify current forms, deadlines, and procedures with official sources before submitting requests or appeals.

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