By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (etanercept) Covered by Cigna in Washington: Complete Approval Guide with Appeals Process

Quick Answer: Cigna Enbrel Coverage in Washington

Most likely covered if: You have moderate-to-severe rheumatoid arthritis or plaque psoriasis, failed at least one conventional therapy, and completed required TB/hepatitis B screening. First step: Have your rheumatologist or dermatologist submit a prior authorization request with detailed medical necessity documentation. Timeline: 72 hours for standard review, 24 hours for expedited. If denied: Washington offers strong external review rights through Independent Review Organizations (IROs) with binding decisions.

Table of Contents

How to Use This Guide

This guide helps Washington residents navigate Cigna's prior authorization process for Enbrel (etanercept), a TNF blocker used for rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. We'll walk through eligibility requirements, documentation needs, and your appeal rights under Washington state law.

If you're dealing with a denial, jump to the Appeals Process section. For initial requests, start with the eligibility triage below.

Eligibility Triage: Do You Qualify?

Likely Eligible If:

  • Diagnosed with moderate-to-severe rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or plaque psoriasis
  • Failed or couldn't tolerate at least one conventional DMARD (like methotrexate) for 3+ months
  • Completed tuberculosis and hepatitis B screening with documented results
  • Prescription from a rheumatologist (for arthritis) or dermatologist (for psoriasis)

Possibly Eligible If:

  • Recently diagnosed but severity criteria met
  • Previous biologic experience with documented failure or intolerance
  • Contraindications to preferred step-therapy options

Not Yet Eligible If:

  • Haven't tried required first-line therapies
  • Missing required lab screenings
  • Mild disease that doesn't meet severity thresholds

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Must get approval before filling PA form with clinical justification Cigna PA Policy
Step Therapy Try preferred alternatives first Records of failed/intolerated therapies Express Scripts Formulary
Specialist Prescription Rheumatologist or dermatologist Specialist consultation notes Cigna PA Requirements
TB Screening Tuberculosis testing required TST or IGRA results FDA Label
Hepatitis B Screening HBV testing before starting HBsAg, anti-HBc, anti-HBs results FDA Safety Requirements
Age Requirement Generally 18+ for most indications Date of birth verification Cigna Coverage Policy

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Severity

  • Who: Your specialist (rheumatologist or dermatologist)
  • What: Document moderate-to-severe disease activity
  • Timeline: During regular appointment

2. Complete Required Screenings

  • Who: Your doctor orders, you get tested
  • What: Tuberculosis screening (TST or QuantiFERON) and hepatitis B panel
  • Timeline: 1-2 weeks for results
  • Note: Must be done before starting Enbrel

3. Document Prior Therapy Failures

  • Who: Your specialist reviews your treatment history
  • What: At least 3 months of conventional DMARD trial (like methotrexate) with inadequate response or intolerance
  • Timeline: Review existing records

4. Submit Prior Authorization Request

  • Who: Your prescriber or their staff
  • What: Complete PA form with all supporting documentation
  • How: Through Cigna provider portal or fax
  • Timeline: Allow 3-5 business days for submission

5. Await Cigna's Decision

  • Standard review: 72 hours from complete submission
  • Expedited review: 24 hours if urgent medical need
  • What to expect: Approval, denial, or request for more information

6. If Approved: Coordinate Specialty Pharmacy

  • Who: Cigna will direct you to Accredo or another specialty pharmacy
  • Timeline: 5-7 days for first shipment
  • Cost: Verify copay and any patient assistance programs

7. If Denied: Begin Appeals Process

  • First step: Request internal appeal within 180 days
  • Timeline: 15-30 days for internal review
  • Next step: External review through Washington IRO if needed

Common Denial Reasons & Solutions

Denial Reason How to Overturn Key Documentation
Step therapy not met Document failure/intolerance of required first-line therapies Detailed treatment history with dates, doses, outcomes
Insufficient severity Provide objective disease activity measures Lab results, imaging, validated assessment scores
Missing TB screening Complete and submit tuberculosis testing TST or IGRA results with interpretation
Non-specialist prescriber Transfer care or get consultation Rheumatology or dermatology consultation notes
Quantity limits exceeded Justify medical need for higher dose/frequency Clinical rationale for dosing requirements
From Our Advocates: We've seen many Cigna denials overturned when prescribers include specific details about why biosimilar alternatives aren't appropriate. Document any previous biosimilar failures, allergies to inactive ingredients, or delivery device preferences that affect adherence. This personalized approach often resonates with reviewers.

Appeals Process for Washington Residents

Washington state provides strong consumer protections for insurance denials. Here's your roadmap:

Internal Appeals (Required First Step)

  • Timeline: Must request within 180 days of denial
  • Process: Submit written appeal to Cigna with additional documentation
  • Decision time: 30 days for standard, 72 hours for urgent
  • Cost: Free

Peer-to-Peer Review

  • When: Often available before or during internal appeal
  • Process: Your doctor speaks directly with Cigna's medical director
  • Timeline: Usually scheduled within 72 hours of request
  • Tip: Prepare your specialist with key clinical points and guideline references

External Review (Independent Review Organization)

Washington's external review process is particularly strong:

  • Eligibility: After exhausting internal appeals or for urgent cases
  • Timeline to request: 180 days from final internal denial
  • IRO decision time: 15 days for standard cases, 72 hours for urgent
  • Cost: Free to you
  • Outcome: Binding on Cigna if overturned

To initiate external review:

  1. Contact Washington Office of the Insurance Commissioner at 800-562-6900
  2. Submit request through OIC appeals portal
  3. Provide all relevant medical records and documentation

When to Contact Washington Regulators

If you experience delays or procedural violations, contact the Washington Office of the Insurance Commissioner Consumer Advocacy line at 800-562-6900.

Medical Necessity Documentation Checklist

For Rheumatoid Arthritis:

  • Confirmed diagnosis by rheumatologist
  • Evidence of moderate-to-severe active disease
  • Laboratory markers (RF, anti-CCP, ESR, CRP)
  • Trial of methotrexate or other DMARD for ≥3 months
  • Documentation of inadequate response or intolerance
  • Functional status assessment

For Plaque Psoriasis:

  • Confirmed diagnosis by dermatologist
  • Body surface area involvement ≥10% OR significant involvement of hands, feet, face, or genitalia
  • Candidate for systemic therapy or phototherapy
  • Trial of phototherapy and/or systemic agent (methotrexate, cyclosporine, acitretin)
  • Documentation of failure, contraindication, or intolerance

Required for All Conditions:

  • Tuberculosis screening (TST or IGRA) with results
  • Hepatitis B screening (HBsAg, anti-HBc, anti-HBs)
  • Complete blood count and liver function tests
  • Treatment plan for latent TB if positive
  • Prescriber attestation of medical necessity

Costs & Patient Support Programs

Typical Costs:

  • List price: >$2,000 per 50mg dose (>$100,000 annually)
  • Cigna copay: Varies by plan tier and specialty pharmacy benefit
  • Deductible: May apply before copay assistance

Money-Saving Options:

  • Enbrel Support Program: Up to $10,000 annually in copay assistance for eligible patients
  • Patient Access Network Foundation: Grants for underinsured patients
  • State pharmaceutical assistance: Washington Apple Health may cover for eligible Medicaid recipients

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial letter, plan policy, and clinical notes to craft targeted, evidence-backed rebuttals. Their platform identifies the exact denial basis and drafts point-by-point responses aligned to your plan's own rules, potentially saving months in the appeals process. Learn more about their services.

Frequently Asked Questions

How long does Cigna prior authorization take for Enbrel in Washington? Standard review takes 72 hours from complete submission. Expedited review for urgent cases takes 24 hours. If Cigna doesn't respond within these timeframes, you may proceed to external review.

What if Enbrel is non-formulary on my Cigna plan? Your prescriber can request a formulary exception by demonstrating medical necessity. This requires showing that preferred alternatives are inappropriate due to contraindications, previous failures, or other clinical factors.

Can I request an expedited appeal in Washington? Yes, if delaying treatment could seriously jeopardize your health. Both Cigna's internal appeals and Washington's external review process offer expedited pathways with shortened timelines.

Does step therapy apply if I failed biosimilars outside Washington? Yes, documented failures of biosimilar etanercept products or other TNF inhibitors from any location should count toward step therapy requirements. Ensure your new Washington provider has complete treatment records.

What happens if the external review upholds Cigna's denial? The external review decision is final for coverage disputes. However, you may still contact the Washington Office of the Insurance Commissioner if you believe procedural errors occurred, or consult with an attorney about potential legal options.

How often do external reviews overturn Cigna denials in Washington? While specific statistics vary, Washington's external review process has a strong track record of overturning denials when proper medical evidence is provided. The state's independent medical experts often rule in favor of patients when specialty medications are clearly indicated.

For additional support navigating these complex approval processes, Counterforce Health offers specialized assistance in crafting appeals that address the specific reasons for denial while incorporating the clinical evidence most likely to result in approval.

Sources & Further Reading

Disclaimer: This guide is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider about treatment options and work with your insurance company's official processes. For assistance with insurance appeals or coverage questions, contact the Washington Office of the Insurance Commissioner at 800-562-6900.

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