By Counterforce Health Team in Enbrel (etanercept) —

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

Answer Box: Getting Enbrel Covered by Cigna in Virginia

Cigna requires prior authorization for Enbrel (etanercept) managed through Express Scripts/Accredo specialty pharmacy. Key requirements: rheumatologist prescription, moderate-to-severe disease documentation, negative TB/hepatitis B screening, and trial of one non-etanercept biologic. Standard approval timeline is 5-15 business days. If denied, Virginia residents can appeal through Cigna's internal process (180 days), then file external review with the State Corporation Commission Bureau of Insurance (120 days from final denial). First step today: Call Cigna at the number on your insurance card to confirm PA requirements for your specific plan.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process in Virginia
  5. Clinician Corner: Medical Necessity Documentation
  6. Cost-Saving Programs
  7. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Cigna plans PA form via provider portal Cigna PA Policy
Prescriber Rheumatologist (RA/PsA/AS) or dermatologist (psoriasis) Provider credentials verification CNF 434 Policy
Age Requirement ≥18 years for most indications Date of birth verification CNF 434 Policy
Disease Severity Moderate-to-severe documented DAS28, HAQ, PASI scores CNF 434 Policy
Step Therapy Trial of 1 non-etanercept biologic Treatment history with outcomes CNF 434 Policy
Screening Negative TB test and hepatitis B panel Lab results ≤12 months old CNF 434 Policy
Quantity Limits Standard 50mg weekly dosing Clinical justification for variations CNF 434 Policy

Step-by-Step: Fastest Path to Approval

1. Verify PA Requirements (Patient)

Timeline: Same day
Action: Call Cigna member services (number on insurance card) to confirm your plan requires PA for Enbrel
Document: Note reference number and representative name

2. Gather Required Documentation (Clinic Staff)

Timeline: 1-3 days
Action: Collect diagnosis codes (ICD-10), disease severity scores, prior treatment records, and recent lab results
Key Documents: TB test results, hepatitis B panel, previous biologic trial records

3. Complete Screening Requirements (Patient/Provider)

Timeline: 1-7 days if tests needed
Action: Ensure TB test (TST or IGRA) and hepatitis B screening completed within 12 months
Submit to: Ordering physician for review

4. Submit Prior Authorization (Provider)

Timeline: 1-2 days
Action: Submit PA via Cigna provider portal or call 1-800-882-4462
Include: Medical necessity letter, clinical documentation, lab results

5. Track Decision (Patient/Provider)

Timeline: 5-15 business days standard; 72 hours expedited
Action: Monitor via provider portal or call Cigna for status updates
Next Step: If approved, Accredo specialty pharmacy will contact for enrollment

6. Appeal if Denied (Patient/Provider)

Timeline: Within 180 days of denial
Action: File internal appeal via Cigna portal or mail
Escalation: External review with Virginia SCC if internal appeals exhausted

7. Fill Prescription (Patient)

Timeline: 3-7 days after approval
Action: Complete Accredo enrollment and coordinate delivery
Support: Contact manufacturer patient assistance if needed

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Lack of Prior Authorization Submit complete PA with all requirements Medical necessity letter, clinical notes, lab results
Inadequate Documentation Provide detailed severity scores and functional assessments DAS28 >3.2, HAQ >0.5, PASI >10 (condition-specific)
Missing Step Therapy Document previous biologic trial and reason for discontinuation Treatment timeline, adverse events, lack of efficacy
Incomplete Screening Submit current TB and hepatitis B test results Lab reports dated within 12 months
Non-Specialist Prescription Transfer prescription to qualified rheumatologist or dermatologist Provider credentials and specialty certification
Quantity Limit Exceeded Justify dosing with clinical rationale Weight-based calculations, response data, guidelines
Tip: When appealing, address each specific denial reason point-by-point with supporting documentation. Generic appeals are less likely to succeed.

Appeals Process in Virginia

Internal Appeals with Cigna

First Level Internal Appeal

  • Deadline: 180 days from denial notice
  • How to File: Via Cigna member portal or mail to address on denial letter
  • Timeline: 30 days for standard; 72 hours for expedited
  • Required: Copy of denial letter, additional medical records, physician statement

Second Level Internal Appeal

  • Automatic: If first level denied
  • Timeline: Additional 30 days
  • Review: Independent medical professional

Virginia External Review Process

After exhausting Cigna's internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance.

Eligibility Requirements:

  • Denial based on medical necessity, appropriateness, or effectiveness
  • Internal appeals completed (or deemed exhausted)
  • Request filed within 120 days of final adverse determination

How to File External Review:

  1. Download Form 216-A from SCC Bureau of Insurance
  2. Include all denial letters, medical records, and provider recommendations
  3. Submit via:
    • Email: [email protected]
    • Fax: (804) 371-9915
    • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Timeline:

  • Standard Review: 45 days from request receipt
  • Expedited Review: 72 hours for urgent cases
  • Decision: Binding on Cigna if overturned
Note: Virginia offers expedited external review for cancer treatments without requiring exhaustion of internal appeals—a special provision reflecting the state's commitment to timely care.

Clinician Corner: Medical Necessity Documentation

Essential Elements for Medical Necessity Letter

Patient Demographics & Diagnosis

  • ICD-10 codes with specificity (e.g., M05.771 for RA right ankle/foot)
  • Disease duration and progression
  • Current functional status

Disease Severity Documentation

  • Rheumatoid Arthritis: DAS28 >3.2, CDAI >10, HAQ >0.5
  • Psoriatic Arthritis: Active joint count, skin involvement (BSA)
  • Ankylosing Spondylitis: ASDAS >2.1, BASFI scores
  • Plaque Psoriasis: PASI >10, BSA >10%, DLQI >10

Prior Treatment History

  • Conventional DMARDs tried (methotrexate, sulfasalazine, leflunomide)
  • Previous biologic therapy with specific agent, duration, and reason for discontinuation
  • Adverse events or contraindications to alternatives

Clinical Rationale for Enbrel

  • Why etanercept is most appropriate choice
  • Expected treatment goals and monitoring plan
  • References to FDA labeling and clinical guidelines

Supporting Documentation Checklist

  • Complete medical records from past 12 months
  • Laboratory results (TB screening, hepatitis B panel, CBC, liver function)
  • Imaging studies if relevant (X-rays, MRI for structural damage)
  • Previous treatment records with outcomes
  • Specialist consultation notes
  • Patient-reported outcome measures

Cost-Saving Programs

Manufacturer Support Programs

Enbrel Support Program

  • Copay assistance up to $10,000 annually for eligible patients
  • Income requirements and insurance restrictions apply
  • Enrollment information available online

Foundation Assistance

Patient Access Network Foundation

  • Grants for autoimmune conditions
  • Income-based eligibility (typically up to 500% federal poverty level)
  • Applications processed within 2-3 business days

State Resources

Virginia residents may qualify for additional assistance through:

  • Virginia Medicaid (expanded coverage as of 2019)
  • State pharmaceutical assistance programs
  • Hospital charity care programs

When exploring coverage challenges, patients and providers in Virginia can benefit from specialized support. Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific basis for denial and craft point-by-point rebuttals aligned with the payer's own rules.

Frequently Asked Questions

How long does Cigna prior authorization take for Enbrel in Virginia? Standard PA decisions are made within 5-15 business days. Expedited reviews for urgent medical situations are completed within 72 hours when physician certification of urgency is provided.

What if Enbrel is non-formulary on my Cigna plan? You can request a formulary exception through Cigna's appeals process. Your doctor must provide clinical justification for why formulary alternatives are inappropriate or have failed.

Does step therapy apply if I failed biologics in another state? Yes, treatment history from any location counts toward step therapy requirements. Ensure your new Virginia provider has complete records of previous trials and outcomes.

Can I request an expedited appeal in Virginia? Yes, both Cigna internal appeals and Virginia external reviews offer expedited pathways when delay could seriously jeopardize health. Physician certification of urgency is required.

What happens if Virginia external review overturns Cigna's denial? The decision is binding on Cigna. They must authorize coverage within 24 hours for expedited reviews or 1-3 days for standard reviews, per Virginia law.

Are there alternatives if Enbrel is still denied? Etanercept biosimilars (Erelzi, Eticovo) may be preferred on some formularies. Other TNF inhibitors like Humira biosimilars or different mechanism biologics (IL-17, JAK inhibitors) may be options.

How much does external review cost in Virginia? Virginia does not charge fees for external review. The process is free to consumers, making it an accessible option for appealing wrongful denials.

From our advocates: We've seen many Virginia patients successfully obtain Enbrel coverage after initial denials by ensuring their rheumatologist documents specific disease activity scores and includes detailed records of previous treatment failures. The key is addressing each denial reason systematically with objective clinical data rather than submitting generic appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with your insurance provider and consult healthcare professionals for medical decisions.

For additional support with Virginia insurance issues, contact:

  • Virginia State Corporation Commission Bureau of Insurance: 1-877-310-6560
  • Virginia Managed Care Ombudsman: 1-877-310-6560
  • Virginia Poverty Law Center: Health assistance for coverage appeals

Sources & Further Reading

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