By Counterforce Health Team in Elelyso (taliglucerase alfa) —

How to Get Elelyso (taliglucerase alfa) Covered by Cigna in Florida: Complete Guide to Forms, Appeals & Approval

Answer Box: Getting Elelyso Covered by Cigna in Florida

Fastest path to approval: Submit prior authorization through CoverMyMeds or ExpressPAth with confirmed Type 1 Gaucher disease diagnosis, specialist prescriber, and documentation of medical necessity. If denied, file internal appeal within 180 days, then external review through Florida Department of Financial Services (1-877-693-5236). Start today: Have your doctor check if PA is required and gather your diagnosis confirmation, prior therapy records, and insurance information.

Table of Contents

Verify Your Plan & Find Forms

Before starting the approval process, confirm your specific Cigna plan details and whether Elelyso requires prior authorization.

Step 1: Check Your Coverage

  • Log into your Cigna member portal or call the number on your insurance card
  • Verify if Elelyso (taliglucerase alfa) is on your plan's formulary
  • Confirm whether prior authorization is required for specialty medications

Step 2: Locate Current Forms Most Cigna specialty drugs are managed through Express Scripts/Accredo. The current prior authorization process uses electronic submissions, but paper forms remain available as backup.

Note: Forms and requirements update regularly. Always verify you're using the most current version from official Cigna resources.

Prior Authorization Forms & Requirements

Electronic Submission (Preferred Method)

For 2024, Cigna requires electronic prior authorization submissions through these platforms:

  • CoverMyMeds (most recommended)
  • ExpressPAth (Express Scripts portal)
  • MyAccredoPatients (for specialty medications)
  • Surescripts (EMR integration)

Paper Form Backup

If electronic options aren't available, use the Cigna Medication Prior Authorization Form and fax to 1-866-873-8279.

Required Information for Elelyso PA

Your physician must provide:

  • Patient demographics and Cigna member ID
  • Confirmed Type 1 Gaucher disease diagnosis (enzyme deficiency test results or genetic confirmation)
  • Specialist prescriber (hematologist, geneticist, or endocrinologist)
  • Clinical rationale for Elelyso specifically
  • Prior therapy history (other ERTs tried, outcomes, intolerances)
  • Dosing details (60 U/kg every 2 weeks is typical starting dose)
  • Treatment goals and monitoring plan

Submission Portals & Electronic Options

Platform Access Best For Notes
CoverMyMeds Online portal All Cigna/Express Scripts PA Fastest processing, real-time status
ExpressPAth Express Scripts provider portal Express Scripts only Can request, renew, or appeal
MyAccredoPatients Accredo prescriber portal Specialty drugs via Accredo Includes referral capability
Surescripts EMR integration All payers Real-time approval in workflow

Pro Tip: CoverMyMeds typically provides the fastest turnaround and real-time status updates for Cigna prior authorizations.

Fax Numbers & Mailing Addresses

Primary Fax Numbers

  • Prior Authorization: 1-866-873-8279
  • Appeals: 860-731-3452 (Cigna Healthcare National Appeals Organization)
  • Accredo Specialty Pharmacy: 888-302-1028

Cover Sheet Tips

  • Mark "URGENT" or "EXPEDITED" if applicable
  • Include patient name and Cigna member ID on every page
  • Attach complete documentation to avoid delays
  • Request confirmation of receipt

Specialty Pharmacy Setup with Accredo

Since Elelyso is typically dispensed through specialty pharmacy, you'll likely need to enroll with Accredo.

Enrollment Steps

  1. Physician completes Accredo referral form
  2. Fax to 888-302-1028 with insurance cards (front and back)
  3. Patient registers at MyAccredoPatients.com
  4. Accredo coordinates with Cigna for PA approval
  5. First shipment scheduled after approval

Transfer from Another Pharmacy

If you're currently getting Elelyso elsewhere:

  • Have your current pharmacy fax prescription details to Accredo (888-302-1028)
  • Provide insurance information and physician contact
  • Allow 3-5 business days for transfer processing

Support Lines & Case Management

Patient Support

  • Cigna Customer Service: Number on your insurance card
  • Accredo Patient Support: 844-516-3319
  • Florida Insurance Helpline: 1-877-693-5236

Provider Support

  • Cigna Provider Services: Check provider portal for current number
  • Express Scripts Provider Help: Available through ExpressPAth portal
  • Accredo Provider Line: 844-516-3319

What to Ask When You Call

  • "Is prior authorization required for Elelyso under my specific plan?"
  • "What's the current status of my PA request?"
  • "Can you expedite this request due to medical urgency?"
  • "What additional documentation do you need?"

Florida Insurance Appeals & External Review

If your initial prior authorization is denied, Florida law provides specific appeal rights.

Internal Appeals Process

  • Timeline: 180 days from denial notice to file
  • Standard Review: 72 hours for future treatments
  • Expedited Review: 24 hours for urgent cases
  • How to File: Cigna formulary exception process

External Review (After Internal Appeal)

Important: You must complete internal appeals before requesting external review, unless the insurer fails to follow proper procedures.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documentation Needed
"Not medically necessary" Provide specialist letter with clinical rationale Gaucher disease confirmation, symptom severity, treatment goals
"Step therapy required" Request exception based on medical history Prior ERT trials, failures, or contraindications
"Non-formulary medication" File formulary exception Comparison to formulary options, clinical superiority argument
"Quantity limits exceeded" Justify dosing based on weight/severity Current weight, BSA calculation, dosing guidelines
"Specialist required" Ensure prescriber credentials are clear Board certification in relevant specialty

Appeals Timeline for Cigna in Florida

Day 1: Denial Received
↓
Days 1-180: File Internal Appeal
↓
Days 1-72: Standard Internal Review
(24 hours if expedited)
↓
If Denied: External Review Available
↓
Days 1-120: File External Review Request
↓
Final Binding Decision

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific denial basis—whether it's prior authorization criteria, step therapy, or medical necessity—then drafts point-by-point rebuttals aligned with your plan's own rules. For complex cases like Elelyso appeals, they pull the right clinical evidence and weave it into appeals that meet Cigna's procedural requirements while tracking deadlines and required documentation.

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Elelyso in Florida? A: Standard reviews take up to 72 hours. Expedited reviews (for urgent medical situations) are completed within 24 hours.

Q: What if Elelyso isn't on Cigna's formulary? A: Your physician can request a formulary exception by documenting that formulary alternatives are ineffective or harmful for your specific case.

Q: Can I get expedited approval for Elelyso? A: Yes, if your physician certifies that delays would seriously jeopardize your health or ability to regain maximum function.

Q: Does step therapy apply if I've been stable on Elelyso? A: Generally no. If you're currently stable on Elelyso, document this in your appeal as continuation of effective therapy.

Q: What's the cost of Elelyso with Cigna coverage? A: Costs vary by plan. After approval, your specialty pharmacy copay applies. Pfizer may offer patient assistance programs for eligible patients.

Q: Who can file an appeal on my behalf? A: You, your physician, or an authorized representative can file appeals. Some patients use services like Counterforce Health to ensure appeals include all necessary clinical evidence and meet procedural requirements.

When to Contact Florida Regulators

Contact the Florida Department of Financial Services if:

  • Cigna fails to meet appeal deadlines
  • You're not receiving proper notice of decisions
  • The insurer isn't following Florida insurance regulations
  • You need help navigating the external review process

Contact Information:

  • Phone: 1-877-693-5236 (in Florida) or 850-413-3089
  • Email: [email protected]
  • Hours: Monday-Friday, 8 AM-5 PM EST

Update Cadence: Staying Current

Insurance requirements change regularly. Check for updates:

  • Monthly: Verify your plan's current formulary status
  • Quarterly: Review any plan changes or new requirements
  • Annually: Confirm specialty pharmacy network and preferred forms
  • Before appeals: Always use the most current forms and contact information

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance coverage decisions are made by your specific plan. For personalized guidance on your coverage situation, consult with your healthcare provider and insurance company. Florida regulations and insurer policies may change; always verify current requirements through official sources.

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