By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by Cigna in Georgia: Complete PA Guide with Forms and Appeals Timeline

Answer Box: Cresemba (isavuconazole) requires prior authorization from Cigna for invasive aspergillosis and mucormycosis. Submit PA via CoverMyMeds or Surescripts portal with confirmed diagnosis, culture results, and ID specialist documentation. If denied, you have 180 days for internal appeal, then 60 days for Georgia DOI external review. Start with your infectious disease specialist gathering treatment history and guideline citations to address step therapy requirements.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Distribution
  5. Step-by-Step Approval Process
  6. Common Denial Reasons & Solutions
  7. Appeals Timeline for Georgia
  8. Medical Necessity Documentation
  9. Cost Considerations
  10. FAQ

Plan Types & Coverage Implications

Your Cigna plan type determines referral requirements and coverage pathways for Cresemba (isavuconazole):

HMO/Network/SureFit Plans

  • Referral required from PCP to infectious disease specialist for highest coverage level
  • PCP must submit written referral to Cigna before specialist visit
  • Only in-network providers covered at full benefit

PPO/EPO/Open Access Plans

  • No referral needed for infectious disease specialists
  • Can see in-network or out-of-network providers (different cost-sharing)
  • Direct access to specialty care

Medicare Advantage (Georgia PPO)

  • No referrals required for any specialty care
  • Both in-network and out-of-network options available
Note: Check your ID card or call the number on your card to confirm your specific plan type and referral requirements.

Formulary Status & Tier Placement

Cigna places Cresemba on specialty tiers with prior authorization across most plan types:

Plan Type Tier Placement PA Required Specialty Pharmacy
Commercial 4-Tier Tier 2 (Preferred Brand) Yes Often required
Premier Access Tier 4 (Specialty) Yes Required
Medicare Part D Tier 5/Specialty Yes Required

Alternative Agents on Lower Tiers:

  • Fluconazole (Diflucan): Tier 3 or lower
  • Voriconazole: Often preferred first-line
  • Generic azoles: Lower cost-sharing

Source: Cigna National Formulary

Prior Authorization Requirements

Cigna's Cresemba PA policy covers specific FDA-approved indications:

Approved Uses:

  • Invasive aspergillosis treatment (6 months duration)
  • Invasive mucormycosis treatment (6 months duration)
  • Pediatric patients ≥6 years weighing ≥16 kg

Required Documentation:

  • Confirmed or probable invasive fungal infection diagnosis
  • Culture results, imaging, or pathology when available
  • Infectious disease specialist consultation notes
  • Prior antifungal therapy history and outcomes
  • Medical rationale if voriconazole cannot be used

Submission Methods:

  1. Electronic PA (preferred): Surescripts or CoverMyMeds
  2. Phone: 1-800-882-4462 for urgent cases
  3. Forms: Cigna General Medication Prior Authorization Form

Specialty Pharmacy Distribution

Cresemba is typically dispensed through specialty pharmacies for Cigna members:

Primary Options:

  • Accredo (Cigna's preferred specialty pharmacy)
  • Express Scripts specialty network
  • Plan-contracted specialty pharmacies

Setup Process:

  1. Prescriber sends prescription to designated specialty pharmacy
  2. Pharmacy contacts patient for delivery coordination
  3. Prior authorization must be approved before dispensing
  4. Home delivery or clinic delivery arranged
Tip: Ask your prescriber's office to coordinate with the specialty pharmacy during PA submission to avoid delays.

Step-by-Step Approval Process

1. Gather Required Documentation

Patient/Family:

  • Insurance card with member ID
  • Complete list of prior antifungal medications tried
  • Hospital records if applicable

Prescriber:

  • Culture/pathology results showing invasive fungal infection
  • Imaging studies (CT chest/sinuses, MRI if CNS involvement)
  • Documentation of failed/contraindicated alternatives
  • IDSA or specialty guideline citations

2. Submit Prior Authorization

Timeline: 72 hours for standard review, 24-72 hours for expedited Method: Electronic PA through provider portal (preferred) Required fields:

  • Patient demographics and insurance information
  • Diagnosis codes (ICD-10)
  • Specific indication (invasive aspergillosis vs. mucormycosis)
  • Prescriber attestation of medical necessity

3. Monitor Status

  • Check PA status through provider portal
  • Follow up within 48-72 hours if no response
  • Request expedited review for urgent cases

4. If Approved

  • Prescription routed to specialty pharmacy
  • Patient contacted for delivery setup
  • Treatment can begin per prescribed regimen

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Documentation Needed
Step therapy not completed Document voriconazole failure/contraindication Prior therapy records, adverse event notes
Insufficient diagnosis documentation Provide culture/pathology confirmation Lab reports, imaging, ID consult notes
Non-formulary status Request formulary exception Medical necessity letter, guideline citations
Experimental/investigational Demonstrate FDA-approved indication FDA label, IDSA guidelines

Most Common Issues:

  • Missing step therapy documentation (60-70% of initial denials)
  • Incomplete infectious disease specialist notes
  • Lack of culture confirmation for probable cases

Appeals Timeline for Georgia

Georgia residents have specific rights for appealing Cigna denials:

Internal Appeals (Cigna)

Level 1:

  • Deadline: 180 days from denial notice
  • Decision time: 30 days standard, 24-72 hours expedited
  • Who can file: Patient, prescriber, or authorized representative

Level 2 (if applicable):

  • Deadline: 60 days from Level 1 decision
  • Decision time: 30-60 days

External Review (Georgia DOI)

Eligibility: After completing internal appeals or concurrent with expedited internal for urgent cases

  • Deadline: 60 days from final Cigna denial
  • Decision time: 30 days standard, 72 hours expedited
  • Cost: Free to patient
  • Binding: Yes, Cigna must comply with favorable decisions

How to File:

  1. Complete Georgia external review application
  2. Attach all Cigna denial letters and appeal responses
  3. Include updated medical necessity letter
  4. Submit to Georgia Office of Insurance Commissioner
Georgia-Specific Advantage: External review decisions are binding on insurers and provide independent medical expert evaluation.

Medical Necessity Documentation

Clinician Corner: Essential Elements

Diagnosis Documentation:

  • Specific organism identification when available
  • Site of infection (pulmonary, CNS, disseminated)
  • Host risk factors (neutropenia, transplant, immunosuppression)
  • Imaging findings consistent with invasive disease

Treatment Rationale:

  • Prior therapy failures with specific agents and reasons
  • Contraindications to preferred alternatives
  • Drug interactions with current medications
  • Organ dysfunction affecting drug choice

Guideline Support:

Monitoring Plan:

  • Proposed treatment duration (typically 6-12 weeks)
  • Response assessment criteria
  • Safety monitoring protocols

Cost Considerations

Wholesale Acquisition Cost (WAC):

  • IV formulation: $394.38 per vial (372 mg)
  • Oral capsules: $1,620-$1,624 per course

Patient Cost-Sharing:

  • Specialty tier: typically 25-40% coinsurance
  • Annual out-of-pocket maximums apply
  • Deductibles may apply before coverage begins

Financial Assistance Options:

Note: Actual patient costs vary significantly based on specific plan design and deductible status.

When to Escalate

Immediate Escalation Triggers:

  • Life-threatening infection with treatment delays
  • ICU admission due to invasive fungal disease
  • Immunocompromised patient with rapid progression

Georgia Consumer Resources:

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Georgians for a Healthy Future: Consumer assistance and appeal guidance
  • Georgia Legal Services Program: For Medicaid/PeachCare appeals

Counterforce Health specializes in turning insurance denials into evidence-backed appeals for specialty medications like Cresemba. Their platform analyzes denial letters and plan policies to create targeted, guideline-supported appeals that address specific payer requirements. By aligning clinical documentation with plan criteria and pulling relevant citations from FDA labeling and specialty guidelines, they help patients and clinicians navigate complex prior authorization requirements more effectively.

For urgent cases requiring immediate treatment, contact your prescriber to request both expedited internal appeal and concurrent Georgia external review to minimize treatment delays.

FAQ

How long does Cigna PA take in Georgia? Standard review: 72 hours. Expedited review for urgent cases: 24-72 hours. Submit complete documentation to avoid delays.

What if Cresemba is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Emphasize FDA-approved indication and contraindications to formulary alternatives.

Can I request expedited appeal for invasive fungal infection? Yes. Document that delay poses serious health risk. Prescriber should call Cigna and request expedited review citing medical urgency.

Does step therapy apply if I failed voriconazole outside Georgia? Yes, but document the failure thoroughly. Include specific adverse events, ineffectiveness, or contraindications in your PA request.

What happens if Georgia external review favors coverage? Cigna must cover the treatment per Georgia law. The external review decision is binding on the insurer.

Do I need infectious disease specialist for PA approval? While not explicitly required, ID specialist consultation strengthens PA requests and is often expected for complex invasive fungal infections.

Can I appeal if treatment was started before PA approval? Yes, but it's more complex. Submit retrospective PA with urgent medical justification. Include documentation of immediate treatment necessity.

What if my employer plan has different rules? Self-funded employer plans may have different PA criteria. Check with HR benefits department and request specific formulary information.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For additional help with insurance appeals in Georgia, contact Counterforce Health or the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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