By Counterforce Health Team in Elzonris (tagraxofusp-erzs) —

How to Get Elzonris (tagraxofusp-erzs) Covered by Cigna in Washington: Forms, Appeals, and Success Scripts

Answer Box: Getting Elzonris Covered by Cigna in Washington

To get Elzonris (tagraxofusp-erzs) covered by Cigna in Washington for BPDCN treatment:

  1. Submit prior authorization via CoverMyMeds or Cigna's electronic portal with complete BPDCN diagnosis documentation (CD123+, pathology report)
  2. Include CLS monitoring plan detailing inpatient initiation, albumin monitoring, and administration protocols
  3. If denied, file internal appeal within 180 days, then external review through Washington's IRO process (call 1-800-562-6900)

Start today: Verify your Cigna plan covers specialty drugs through Express Scripts/Accredo, then gather pathology reports showing CD123-positive BPDCN diagnosis before submitting the PA request.

Table of Contents

  1. Verify Your Plan Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Medical Necessity Requirements
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Washington
  7. Specialty Pharmacy Setup
  8. Support Contacts
  9. FAQ

Verify Your Plan Coverage

Before starting your Elzonris prior authorization, confirm these coverage basics:

Check Your Formulary Status

  • Log into your Cigna member portal or call member services
  • Search for "Elzonris" or "tagraxofusp-erzs"
  • Note the formulary tier and any restrictions listed

Specialty Drug Management Most Cigna plans manage Elzonris through Express Scripts or Accredo Specialty Pharmacy. Your plan documents will specify which specialty pharmacy network applies.

Tip: If Elzonris isn't on your formulary, you can still request coverage through Cigna's formulary exception process.

Required Forms and Documentation

Prior Authorization Forms

Primary Submission Methods:

Essential Documentation Checklist

Clinical Requirements:

  • Pathology report confirming BPDCN diagnosis
  • CD123-positive immunophenotyping results
  • Prior therapy history (if applicable)
  • Prescriber attestation of medical necessity
  • CLS monitoring and mitigation plan

Administrative Requirements:

  • Patient demographics and insurance information
  • Prescriber NPI and contact information
  • Requested quantity and dosing schedule
  • ICD-10 diagnosis codes for BPDCN

Submission Portals and Methods

Method Portal/Contact Timeline Notes
Electronic PA CoverMyMeds 72 hours standard Fastest option
Electronic PA ExpressPAth 72 hours standard For Express Scripts plans
Phone 1-800-882-4462 Same day start Verbal PA requests
Fax Number on PA form 3-5 business days Include cover sheet

Accredo Integration: If your plan uses Accredo, they coordinate PA requests through their provider portal and will work directly with Cigna on your behalf.

Medical Necessity Requirements

BPDCN Diagnosis Documentation

Cigna requires comprehensive pathologic confirmation of BPDCN:

Required Markers:

  • CD123 positive (strongly expressed in ~95% of BPDCN cases)
  • CD4 positive (nearly always present)
  • CD56 (frequent but not always required)
  • Additional pDC markers: TCL1, TCF4, CD303 (BDCA2) for specificity

Exclusion Markers (must be negative):

  • CD3, CD19, cCD79a (lineage exclusion)
  • MPO, CD14, CD64 (myeloid exclusion)

CLS Monitoring Plan

Elzonris carries a boxed warning for capillary leak syndrome. Your monitoring plan must include:

Administration Requirements:

  • First cycle: inpatient setting with 24-hour observation
  • Subsequent cycles: inpatient or appropriate outpatient setting with 4-hour observation
  • Pre-dose albumin levels ≥3.2 g/dL
  • Daily weight monitoring
  • Blood pressure and cardiac monitoring protocols

Mitigation Protocols:

  • IV albumin administration plan (25g every 12 hours if needed)
  • CLS symptom management procedures
  • Emergency response protocols

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient BPDCN documentation Submit comprehensive pathology report CD123+ immunophenotyping, lineage exclusion markers
Missing CLS monitoring plan Provide detailed safety protocol Inpatient initiation plan, albumin monitoring schedule
Site of care restrictions Request exception or modify setting Justify outpatient administration after first cycle
Quantity limits exceeded Clinical justification for dosing Weight-based calculations, treatment protocol

Formulary Exception Process

If Elzonris is non-formulary or requires step therapy:

  1. Complete formulary exception request through your prescriber
  2. Document clinical rationale for why formulary alternatives are inappropriate
  3. Submit within standard PA timeframe (decisions within 72 hours)
  4. Include supporting evidence from FDA labeling and clinical guidelines

Appeals Process in Washington

Internal Appeals (First Step)

Timeline: 180 days from denial notice Method: Submit through Cigna member portal or mail appeal letter Required: Original denial letter, clinical documentation, appeal rationale

External Review (Independent Review Organization)

If Cigna upholds their denial:

Contact: Washington Office of Insurance Commissioner

Timeline:

  • Request within 60 days of final internal denial
  • Standard review: 20 days for fully insured plans
  • Expedited review: 72 hours if health at risk

Process:

  1. Request external review from Cigna or directly through OIC
  2. Submit all relevant medical records and correspondence
  3. Independent medical experts review your case
  4. Decision is binding on Cigna if approved
Note: Washington's external review process has helped many patients access specialty medications initially denied by insurers.

Specialty Pharmacy Setup

Accredo Enrollment Process

  1. Prescriber submits referral through Accredo provider portal
  2. Patient enrollment call (Accredo contacts patient within 24-48 hours)
  3. Insurance verification and PA coordination
  4. Delivery scheduling and patient education

Patient Responsibilities

  • Provide complete insurance information
  • Schedule delivery and administration appointments
  • Maintain required lab monitoring schedule
  • Report any side effects immediately

Support Contacts

Patient Support Lines

Need Contact Hours
Cigna Member Services Number on insurance card 24/7
Express Scripts 1-800-753-2851 24/7
Accredo Patient Support 1-800-803-2523 8 AM - 8 PM ET

Provider Support

  • Cigna Provider Services: 1-800-882-4462
  • Prior Authorization Status: CoverMyMeds portal or Cigna provider line
  • Peer-to-Peer Review: Request through PA denial notice or provider services

Washington State Resources

  • Insurance Commissioner Consumer Hotline: 1-800-562-6900
  • Appeal Guidance: insurance.wa.gov/appeals-guide.pdf
  • Complaint Filing: Online at insurance.wa.gov or fax (360) 586-2018

FAQ

How long does Cigna prior authorization take for Elzonris? Standard electronic submissions receive decisions within 72 hours. Complex cases requiring medical review may take up to 14 days.

What if Elzonris isn't on my Cigna formulary? You can request a formulary exception with clinical justification. Your prescriber must document why formulary alternatives are inappropriate for your BPDCN treatment.

Can I get an expedited appeal in Washington? Yes, if delay in treatment could seriously jeopardize your health. Request expedited review through Cigna initially, then through Washington's IRO process if needed (72-hour decision timeline).

Does step therapy apply to Elzonris for BPDCN? BPDCN is a rare, aggressive cancer with limited treatment options. Step therapy requirements are uncommon, but if imposed, can be appealed with clinical justification.

What documentation do I need for an external review? Include your original denial letter, all appeal correspondence, complete medical records, pathology reports, and any additional clinical evidence supporting Elzonris medical necessity.

How much does Elzonris cost without insurance? List price is approximately $38,579 per 1,000 mcg vial. Stemline Therapeutics offers patient assistance programs that may help with costs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements, increasing approval rates for specialty medications like Elzonris.

When dealing with complex prior authorizations or appeals, Counterforce Health can help streamline the process by identifying the exact denial basis and crafting point-by-point rebuttals using the right clinical evidence and procedural requirements for your specific Cigna plan in Washington.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact Washington's Office of Insurance Commissioner for specific appeals guidance. Coverage policies and procedures may change; verify current requirements with your insurer and the official sources linked above.

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