By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (etanercept) Covered by Cigna in Michigan: Complete Prior Authorization Guide

Answer Box: Getting Enbrel Covered by Cigna in Michigan

Eligibility: Cigna covers Enbrel (etanercept) for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis with prior authorization. You must be over 18, prescribed by a rheumatologist, and have tried another biologic (excluding etanercept biosimilars).

Fastest path: Your doctor submits a prior authorization through Cigna's provider portal with TB/hepatitis B screening, severity documentation, and prior therapy records. Approval takes 6 months initially.

First step today: Call Cigna at the number on your card to confirm Enbrel requires PA, then ask your rheumatologist to start the authorization process through Accredo specialty pharmacy.

Table of Contents

  1. Cigna's Coverage Policy for Enbrel
  2. Prior Authorization Requirements
  3. Step Therapy and Exceptions
  4. Required Diagnostics and Screening
  5. Specialty Pharmacy Requirements
  6. Medical Necessity Documentation
  7. Appeals Process in Michigan
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Programs
  10. FAQ

Cigna's Coverage Policy for Enbrel

Cigna covers Enbrel (etanercept) as a specialty medication requiring prior authorization across all plan types—HMO, PPO, and Medicare plans. The drug is typically managed through Express Scripts/Accredo specialty pharmacy and requires clinical justification before approval.

Key Policy Points:

  • Prior authorization required for all new starts
  • Specialty pharmacy mandatory (usually Accredo)
  • Initial approval: 6 months if criteria met
  • Renewal approval: 1 year with documented clinical response
  • Age requirement: Must be over 18 years old

Find your specific plan's formulary and requirements through the myCigna member portal or by calling the number on your insurance card.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Age > 18 years Adult indication only Date of birth verification Cigna PA Policy
Rheumatologist prescription Specialist requirement Prescriber credentials Cigna PA Policy
TB screening Within 12 months Negative TB test results CMS Quality Measure
Step therapy Prior biologic trial Treatment history records Cigna PA Policy
Disease severity Moderate to severe Clinical assessment scores Cigna Medical Policy

Step Therapy and Exceptions

Cigna requires that patients try one biologic other than etanercept before Enbrel approval. Importantly, biosimilars of etanercept (like Erelzi or Eticovo) do not count toward meeting this step therapy requirement.

Step-by-Step: Fastest Path to Approval

  1. Confirm diagnosis with rheumatologist and document moderate to severe disease activity
  2. Complete required screening (TB test, hepatitis B panel) within 12 months
  3. Document prior biologic trial (excluding etanercept biosimilars) with failure/intolerance
  4. Submit PA request through Cigna provider portal with all supporting documentation
  5. Await determination (typically 5-15 business days for standard review)
  6. Fill at Accredo once approved (they'll contact you for enrollment)
  7. Schedule follow-up at 6 months for renewal authorization

Medical Exceptions to Step Therapy

You can bypass step therapy requirements if you have:

  • Contraindications to preferred agents (documented allergies, drug interactions)
  • Previous intolerance with severe adverse effects
  • Clinical urgency where delay would cause significant harm

Your rheumatologist must provide detailed clinical justification for any exception request.

Required Diagnostics and Screening

Before Cigna approves Enbrel, you must complete specific screening tests due to the drug's immunosuppressive effects and FDA black box warnings.

Mandatory Screening Tests

Tuberculosis Screening (within 12 months):

  • TB skin test (TST) or interferon-gamma release assay (IGRA)
  • Chest X-ray
  • If positive: complete latent TB treatment before starting Enbrel

Hepatitis B Screening:

  • HBsAg, anti-HBc, anti-HBs testing
  • Active hepatitis B requires antiviral management before approval

Additional Labs:

  • Complete blood count (CBC)
  • Liver function tests
  • Assessment for active infections
Note: CMS Quality Measure #176 specifically requires TB testing before TNF inhibitor initiation, making this a strict requirement across all payers.

Specialty Pharmacy Requirements

Cigna members in Michigan must fill Enbrel through Accredo, Cigna's designated specialty pharmacy. Express Scripts handles standard medications, but specialty biologics like Enbrel are routed through Accredo's specialized network.

Accredo Enrollment Process

  1. Doctor sends prescription directly to Accredo
  2. Accredo contacts you within 24-48 hours to verify insurance and shipping address
  3. Benefits verification and copay assistance coordination
  4. Home delivery with temperature-controlled shipping (no extra cost)
  5. Ongoing support including injection training and refill reminders

Accredo Contact: 877-826-7657

Site of Care Requirements

  • Self-injection: Home administration after training
  • Provider administration: Covered at rheumatology offices
  • Hospital/infusion center: May require additional authorization

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your rheumatologist's prior authorization request should include:

Diagnosis and Severity:

  • Confirmed RA, PsA, AS, or plaque psoriasis diagnosis with ICD-10 codes
  • Disease activity scores (DAS28, RAPID-3, SDAI for RA; ASDAS for AS)
  • Functional impairment documentation (HAQ scores, work disability)

Prior Treatment History:

  • Detailed record of previous biologics tried (excluding etanercept biosimilars)
  • Reasons for discontinuation (lack of efficacy, adverse effects, contraindications)
  • Duration of each trial and response assessment

Clinical Rationale:

  • Why Enbrel is specifically indicated for this patient
  • Expected treatment goals and monitoring plan
  • Citations from FDA labeling or ACR/EULAR guidelines

Supporting Evidence:

  • Recent lab values (inflammatory markers, liver function)
  • Imaging studies showing joint damage or inflammation
  • Specialist consultation notes

Appeals Process in Michigan

If Cigna denies your Enbrel request, Michigan provides robust appeal rights through both internal insurer appeals and external review by the Department of Insurance and Financial Services (DIFS).

Appeals Timeline

Step Deadline to File Decision Timeframe Expedited Option
Cigna Internal Appeal 180 days after denial 30-60 days 72 hours
Michigan DIFS External Review 127 days after final internal denial 60 days 72 hours

Internal Appeal with Cigna

  1. File within 180 days of receiving the denial letter
  2. Submit through Cigna member portal or mail to address on denial letter
  3. Include supporting documents: medical records, peer-reviewed studies, specialist letters
  4. Request expedited review if delay would harm your health (requires physician certification)

External Review Through Michigan DIFS

If Cigna upholds the denial after internal appeal, you can request an independent external review:

  1. File within 127 days of Cigna's final internal denial
  2. Use DIFS online form or submit paper application
  3. DIFS assigns to Independent Review Organization (IRO)
  4. Decision is binding on Cigna if overturned

Michigan DIFS Contact: 877-999-6442
External Review Form: Available at Michigan.gov/DIFS

Success Rate: Approximately 40% of specialty drug denials are overturned through Michigan's external review process when robust clinical documentation is provided.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Step therapy not met" Prove prior biologic trial (non-etanercept) Treatment records, failure documentation
"Not medically necessary" Demonstrate disease severity Activity scores, functional assessments
"Inadequate TB screening" Complete required testing TB test results within 12 months
"Age restriction" Confirm adult indication Date of birth, adult diagnosis
"Non-specialist prescriber" Transfer to rheumatologist Specialist consultation notes

From Our Advocates

We've seen many Cigna Enbrel denials overturned when patients work closely with their rheumatologist to document disease severity using standardized assessment tools and provide detailed records of prior biologic failures. The key is showing you meet every single criterion in Cigna's policy—missing even one requirement often leads to denial.

Cost Assistance Programs

Even with Cigna coverage, Enbrel can have significant out-of-pocket costs. Several programs can help reduce your expenses:

Manufacturer Support

  • Enbrel Support Program: Up to $25,000 annually in copay assistance
  • Eligibility: Commercial insurance (not Medicare/Medicaid)
  • Application: Enbrel.com/support

Foundation Programs

  • Patient Access Network (PAN): Assistance for underinsured patients
  • HealthWell Foundation: Income-based grants for specialty medications
  • Good Days: Copay and premium assistance programs

State Programs

  • Michigan Medicaid: May cover Enbrel with prior authorization
  • Healthy Michigan Plan: Expanded Medicaid coverage for eligible adults

FAQ

How long does Cigna prior authorization take for Enbrel in Michigan?
Standard prior authorization decisions take 5-15 business days. Expedited reviews (when medically urgent) are decided within 72 hours.

What if Enbrel is non-formulary on my Cigna plan?
You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why preferred alternatives are inappropriate.

Can I request an expedited appeal if Cigna denies Enbrel?
Yes, if your doctor certifies that delay would seriously jeopardize your health. Both Cigna internal appeals and Michigan DIFS external reviews offer expedited pathways with 72-hour decisions.

Does step therapy apply if I tried biologics outside Michigan?
Yes, prior treatment history from any location counts toward meeting step therapy requirements, as long as it's properly documented in your medical records.

What happens if I'm already on Enbrel and switch to Cigna?
Cigna typically honors existing therapy during plan transitions, but you may need to complete a new prior authorization. Contact Cigna immediately upon enrollment to avoid treatment interruptions.

Can my doctor request a peer-to-peer review?
Yes, your rheumatologist can request to speak directly with Cigna's medical director to discuss your case if the initial prior authorization is denied.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to craft targeted, evidence-backed responses. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes more effectively. Learn more at CounterforceHealth.org.

If you're facing challenges getting Enbrel covered by Cigna, remember that persistence and proper documentation are key. Work closely with your rheumatologist to ensure all requirements are met, and don't hesitate to use Michigan's robust appeal process if initially denied. With the right approach and supporting evidence, many patients successfully obtain coverage for this important medication.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage determinations. Coverage policies may change; verify current requirements with Cigna and Michigan DIFS.

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