By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (isavuconazole) Covered by Cigna in Florida: Complete Prior Authorization Guide

Answer Box: Fastest Path to Cresemba Coverage

Cigna requires prior authorization for Cresemba (isavuconazole) in Florida with 6-month approval duration for invasive aspergillosis and mucormycosis. Submit PA within 72 hours of prescription using Cigna's electronic portal or Authorization Request Form. Include confirmed diagnosis, culture/imaging evidence, prior antifungal failures, and ID specialist notes. If denied, file internal appeal within 180 days, then Florida external review through DFS within 4 months. Start today: Have your prescriber call Cigna precertification to initiate the PA request.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all plans Cigna formulary PDL Cigna FL 4-Tier PDL
Approved Indications Invasive aspergillosis, mucormycosis FDA labeling Cigna Cresemba Policy
Approval Duration 6 months initial Policy document Cigna Cresemba Policy
Step Therapy May require voriconazole trial Plan-specific Check member portal
Site of Care Hospital or specialty clinic PA submission Provider documentation
Appeals Deadline 180 days from denial Florida law FL DFS Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who does it: Patient or clinic staff
Timeline: Same day

  • Log into myCigna portal or call member services
  • Confirm Cresemba requires PA on your specific Florida plan
  • Note any quantity limits or step therapy requirements

2. Gather Clinical Documentation

Who does it: Prescribing physician
Timeline: 1-2 days

  • Confirm invasive aspergillosis or mucormycosis diagnosis
  • Document culture results, imaging (CT chest/sinus), pathology
  • Record prior antifungal treatments and outcomes
  • Obtain infectious disease specialist consultation if available

3. Complete Prior Authorization Request

Who does it: Prescriber's office
Timeline: Submit within 72 hours

  • Use Cigna's electronic PA portal when possible
  • If unavailable, complete Authorization Request Form and fax
  • Include all supporting documentation with initial submission

4. Follow Up on Decision

Who does it: Clinic staff
Timeline: Cigna responds within 72 hours standard, 24 hours expedited

  • Track PA status through provider portal
  • Request expedited review if patient's condition is deteriorating
  • Obtain written approval confirmation before dispensing

5. Appeal if Denied (Internal)

Who does it: Prescriber or patient
Timeline: File within 180 days of denial

  • Review denial letter for specific unmet criteria
  • Submit additional documentation addressing gaps
  • Request peer-to-peer review with Cigna medical director

6. External Review (If Internal Appeal Fails)

Who does it: Patient
Timeline: File within 4 months of final denial

  • Submit request to Florida Department of Financial Services
  • Include all previous documentation and correspondence
  • Decision is binding on Cigna if favorable

Medical Necessity Documentation

Your prescriber's PA submission should include these critical elements to meet Cigna's medical necessity criteria:

Clinical Diagnosis Requirements

  • Confirmed invasive aspergillosis: Positive culture from sterile site, galactomannan antigen, or histopathology showing septate hyphae with tissue invasion
  • Confirmed mucormycosis: Tissue biopsy showing broad, pauciseptate hyphae with angioinvasion, or culture growth from sterile site
  • High-risk host factors: Document immunocompromise (neutropenia, transplant, steroids, diabetes/DKA)

Prior Treatment Documentation

According to Cigna's Cresemba policy, include:

  • Previous antifungal therapy trials with dates, doses, and outcomes
  • Reasons for discontinuation (toxicity, drug interactions, treatment failure)
  • Contraindications to first-line agents when applicable

Treatment Plan Details

  • Loading dose: 372 mg every 8 hours × 6 doses, then 372 mg daily
  • Planned treatment duration (typically weeks to months)
  • Monitoring plan for efficacy and safety
  • Surgical debridement plans for mucormycosis cases
Clinician Tip: Reference IDSA guidelines for invasive aspergillosis and current mucormycosis treatment recommendations in your PA letter. Cigna's policy specifically mentions reviewing requests against clinical guidelines.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Medical necessity not established" Provide culture/pathology results Lab reports, imaging, biopsy results
"Step therapy required" Document voriconazole failure/intolerance Treatment records, adverse event notes
"Insufficient prior authorization info" Submit complete clinical packet All missing elements from checklist
"Non-formulary drug" Request formulary exception Medical necessity letter, guideline citations
"Experimental/investigational" Cite FDA approval and guidelines FDA labeling, IDSA recommendations

Appeals Process in Florida

Internal Appeals with Cigna

Florida residents have specific rights under state insurance law when appealing Cigna denials:

Timeline: File within 180 days of denial notice
Process:

  1. Submit written appeal to address on denial letter
  2. Include all supporting medical records and documentation
  3. Request expedited review if delay would jeopardize health
  4. Cigna must respond within 30 days (standard) or 72 hours (expedited)

Required Elements:

  • Copy of original denial letter
  • Prescriber letter explaining medical necessity
  • Additional clinical evidence addressing denial reasons
  • Patient impact statement if applicable

Florida External Review

If Cigna upholds the denial after internal appeal, Florida law provides access to independent external review through the Department of Financial Services.

Eligibility: Available after final internal denial or if Cigna fails to follow proper procedures
Timeline: Request within 4 months of final denial
Process: Submit written request with all documentation to Florida DFS
Decision: Binding on Cigna if favorable; no cost to patient
Contact: Florida DFS Consumer Helpline at 1-877-693-5236

Note: For urgent cases where delay could seriously jeopardize health, you can request expedited external review simultaneously with internal appeal.

Cost Savings and Support Options

Manufacturer Support Programs

CRESEMBA Support Solutions provides free assistance with:

  • Prior authorization submissions and appeals
  • Benefits verification and coverage navigation
  • Patient assistance programs for eligible patients
  • Contact: Astellas Support

Financial Assistance

  • Copay assistance: Available for commercially insured patients
  • Patient assistance programs: For uninsured or underinsured patients
  • Foundation grants: Check with organizations like Patient Access Network Foundation

Counterforce Health Support

If you're facing complex denials or need expert help navigating the appeals process, Counterforce Health specializes in turning insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed rebuttals that align with payer requirements—particularly valuable for specialty medications like Cresemba where documentation requirements are extensive.

When to Escalate Beyond Cigna

Contact Florida Insurance Regulators

If Cigna fails to follow proper procedures or unreasonably delays decisions:

  • Florida Department of Financial Services: File complaint online or call 1-877-693-5236
  • Florida Office of Insurance Regulation: For systemic issues or bad faith concerns
  • Document all interactions with dates, times, and representative names

Consider consulting an attorney if:

  • Cigna fails to acknowledge appeals within required timeframes
  • Multiple inappropriate denials for the same medically necessary treatment
  • Evidence of bad faith or systematic denial patterns
  • Patient's health is deteriorating due to coverage delays

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Cresemba in Florida?
A: Standard PA decisions within 72 hours; expedited reviews within 24 hours if medically urgent. Submit complete documentation to avoid delays.

Q: What if Cresemba is non-formulary on my Cigna plan?
A: Request a formulary exception using the same PA process. Your prescriber must document medical necessity and why formulary alternatives are inappropriate.

Q: Can I get expedited approval if I'm in the ICU?
A: Yes. Request expedited review citing immediate health risk. Provide documentation that delay would seriously jeopardize your condition.

Q: Does Florida step therapy apply if I failed voriconazole in another state?
A: Yes. Document the previous failure with medical records. Florida HB 459 provides automatic exemptions for prior failures within 90 days.

Q: What happens if my appeal is denied?
A: You can request external review through Florida DFS within 4 months. This independent review is binding on Cigna if favorable.

Q: Are there quantity limits on Cresemba?
A: Possibly. Check your specific formulary. If limits don't cover your prescribed regimen, request a quantity limit exception through the same PA process.

Q: Can I continue current Cresemba while appealing a denial for continuation?
A: Florida law may require continued coverage during appeals for ongoing treatments. Confirm with Cigna and document any coverage interruptions.

Q: Who can help if I can't navigate this process alone?
A: Contact CRESEMBA Support Solutions, Florida DFS Consumer Services, or consider services like Counterforce Health that specialize in insurance appeals for specialty medications.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with insurance appeals and coverage issues, contact Florida DFS Consumer Services at 1-877-693-5236.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.