By Counterforce Health Team in Enbrel (etanercept) —

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

Answer Box: Getting Enbrel (etanercept) Covered by Cigna in Texas

Cigna requires prior authorization for Enbrel (etanercept) with step therapy requirements including trials of conventional DMARDs like methotrexate. Submit PA through your rheumatologist via Cigna's provider portal with diagnosis codes (M05/M06 for RA, L40.5 for psoriatic arthritis), screening results, and prior therapy documentation. If denied, file internal appeal within 180 days, then external review through Texas Department of Insurance within 4 months. Standard PA decisions take 5-15 business days; expedited reviews available within 72 hours for urgent cases.

First step today: Call Cigna at the number on your member ID card to confirm your plan's formulary status for Enbrel and PA requirements.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cigna plans Cigna provider portal Cigna PA Policy
Formulary Tier Specialty tier (high copay) Plan formulary document Cigna Formulary
Step Therapy 1-2 prior DMARDs required PA criteria document Step Therapy Requirements
Age Requirements ≥18 years (most indications) Coverage policy Cigna PA Policy
Prescriber Requirements Rheumatologist or specialist PA criteria Cigna PA Policy
Screening Required TB test, hepatitis B panel Within 12 months Cigna PA Policy
Pharmacy Network Accredo specialty pharmacy Mandatory for coverage Express Scripts Network
Appeals Deadline 180 days from denial Texas law Texas DOI Appeals

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who does it: You or your clinic staff
Document needed: Insurance card, member ID
How to submit: Call Cigna member services
Timeline: Same day
Source: Cigna Member Portal

2. Complete Required Screenings

Who does it: Your rheumatologist
Documents needed: TB test results, hepatitis B panel
Timeline: Within 12 months of PA submission
Source: Cigna PA Criteria

3. Document Prior Therapy Failures

Who does it: Your rheumatologist
Documents needed: Treatment records showing ≥1-2 DMARD trials (methotrexate, sulfasalazine, etc.)
Timeline: Must be documented within past 365 days
Source: Step Therapy Policy

4. Submit Prior Authorization

Who does it: Your rheumatologist's office
How to submit: Cigna provider portal or fax
Documents needed: PA form, medical records, lab results
Timeline: 5-15 business days (standard), 72 hours (expedited)
Source: Cigna Provider Portal

5. Enroll in Accredo Specialty Pharmacy

Who does it: You with clinic assistance
Timeline: Can be done concurrently with PA
Source: Express Scripts Accredo

6. Follow Up on Decision

Who does it: You or clinic staff
Timeline: Check status after 5 business days
Next step: If denied, proceed to appeals process

7. Appeal if Denied

Who does it: You with clinic support
Timeline: File within 180 days of denial
Source: Texas Appeals Process

Coding Requirements for Clean Submissions

ICD-10 Diagnosis Codes

Rheumatoid Arthritis:

  • M05.79 (other RA with rheumatoid factor, multiple sites)
  • M06.9 (unspecified RA)

Psoriatic Arthritis:

  • L40.50 (unspecified arthropathic psoriasis)
  • L40.52 (psoriatic arthritis mutilans)
  • L40.53 (psoriatic spondylitis)

Ankylosing Spondylitis: M45.- codes

Plaque Psoriasis: L40.0 (psoriasis vulgaris)

HCPCS Coding for Medical Benefit

J1438: Injection, etanercept, 25 mg

  • 25 mg dose = 1 billing unit
  • 50 mg dose = 2 billing units
  • Use only for physician-supervised administration
  • Pair with CPT 96372 for injection administration
Note: Self-administered Enbrel via autoinjector falls under pharmacy benefit, not medical billing with J1438.

Documentation Requirements

  • Precise ICD-10 codes matching diagnosis
  • Prior therapy dates and outcomes
  • Disease severity scores (DAS28, RAPID-3, ASDAS)
  • Functional assessments (HAQ)
  • Treatment goals and monitoring plan

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Inadequate prior therapy Document ≥1-2 DMARD trials with dates, doses, outcomes Treatment records, pharmacy claims
Missing TB screening Submit negative TB test within 12 months QuantiFERON or TST results
Non-specialist prescriber Transfer care or get consultation Rheumatology referral/consultation notes
Insufficient disease severity Provide objective measures DAS28, joint counts, functional assessments
Missing hepatitis B screening Submit HBV panel results Lab results within 12 months
Quantity limit exceeded Justify higher dose with clinical rationale Weight-based dosing calculations, guidelines

Appeals Playbook for Cigna in Texas

Internal Appeal Process

Timeline: File within 180 days of denial
Standard Review: 30 days for pre-service decisions
Expedited Review: 72 hours if delay would jeopardize health
How to File: Cigna Appeals Portal

Required Documents for Appeal

  • Copy of original denial letter
  • Medical necessity letter from prescriber
  • Treatment history and prior failures
  • Current clinical notes and assessments
  • Relevant clinical guidelines and studies

External Review (Texas IRO)

Timeline: File within 4 months of final internal denial
Standard Review: 20 days
Expedited Review: 5 days for urgent cases
Cost: Free to patient (insurer pays)
Contact: Texas DOI at 1-800-252-3439 or IRO line 1-866-554-4926
Source: Texas Appeals Process

Tip: The external review decision is binding on Cigna. If the IRO overturns the denial, Cigna must cover your Enbrel prescription.

Scripts & Templates

Patient Phone Script for Cigna

"Hi, I'm calling to check the prior authorization status for Enbrel prescribed by Dr. [Name]. My member ID is [Number]. Can you tell me what additional information is needed and the expected timeline for a decision?"

Medical Necessity Letter Template

"Patient has moderate-to-severe [diagnosis] with inadequate response to conventional therapy including [list DMARDs with dates]. Current disease activity scores show [specific measures]. Enbrel is medically necessary based on [ACR/EULAR guidelines] and patient's contraindications to preferred alternatives include [list specific reasons]."

Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for [patient name] regarding Enbrel denial. The patient has failed [specific prior therapies] and meets all clinical criteria per your policy. When can we schedule the physician review?"

Costs & Savings Options

Manufacturer Support Programs

Enbrel Support: Patient assistance and copay cards available
Eligibility: Income and insurance requirements apply
Contact: Visit manufacturer website or call patient support line

Foundation Grants

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Texas State Programs

Limited specialty drug assistance available through state programs. Contact Texas Health and Human Services for eligibility.

When traditional coverage fails, Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating evidence-backed rebuttals that address specific payer criteria. Their platform analyzes denial letters and drafts targeted responses using FDA labeling, peer-reviewed studies, and specialty guidelines to maximize approval chances.

FAQ

How long does Cigna prior authorization take for Enbrel in Texas? Standard PA decisions take 5-15 business days. Expedited reviews are available within 72 hours if your doctor certifies that a delay would jeopardize your health or ongoing treatment.

What if Enbrel is non-formulary on my Cigna plan? You can request a formulary exception through Cigna's pharmacy team. Your doctor must provide clinical rationale for why preferred alternatives aren't appropriate for your condition.

Can I request an expedited appeal in Texas? Yes, both internal appeals (72 hours) and external IRO reviews (5 days) have expedited pathways if delay would jeopardize your health or ability to regain maximum function.

Does step therapy apply if I've used Enbrel in another state? If you've been on Enbrel within the past 365 days, you may qualify for continuation of therapy without stepping back to other DMARDs. Document your prior use with pharmacy records.

What happens if my internal appeal is denied? You can file for external review through the Texas Department of Insurance within 4 months. This independent review is binding on Cigna and free to you.

How do I prove medical necessity for Enbrel? Your rheumatologist should document disease severity scores, prior therapy failures with specific dates and reasons for discontinuation, contraindications to alternatives, and treatment goals with monitoring plans.

Can I use Enbrel copay cards with Cigna? Manufacturer copay assistance may be available depending on your specific Cigna plan. Commercial plans typically allow copay cards, but Medicare plans may not.

What if I need Enbrel urgently while waiting for approval? Ask your doctor to submit an expedited PA request and consider requesting samples from the manufacturer or temporary coverage through Counterforce Health's emergency access programs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently, and individual circumstances vary. Always verify current requirements with Cigna directly and consult your healthcare provider for medical decisions. For additional help with complex appeals, contact the Texas Department of Insurance at 1-800-252-3439 or consider working with specialized advocacy services like Counterforce Health that focus on turning insurance denials into successful appeals through evidence-based approaches.

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