By Counterforce Health Team in Exondys 51 (eteplirsen) —

How to Get Exondys 51 (Eteplirsen) Covered by Cigna in Texas: Complete Prior Authorization Guide

Answer Box: Fastest Path to Exondys 51 Coverage

To get Exondys 51 (eteplirsen) covered by Cigna in Texas: Submit prior authorization through CoverMyMeds or fax to (855) 840-1678 with genetic testing confirming exon 51-skipping DMD mutation, 6-minute walk test ≥180 meters, and prescription from a neuromuscular specialist. If denied, you have 180 days to appeal internally, then request free external review through Texas Independent Review Organization. Start today: Verify your plan covers specialty drugs under medical benefit and confirm your neurologist is in-network.

Table of Contents

  1. Before You Start: Plan Verification
  2. What You Need to Gather
  3. Submit Your Prior Authorization
  4. Follow-Up and Timelines
  5. If You're Asked for More Information
  6. If Your Request is Denied
  7. Appeals Process in Texas
  8. Renewal and Reauthorization
  9. Cost Assistance Options
  10. Quick Reference Checklist

Before You Start: Plan Verification

Confirm Your Coverage Type

Exondys 51 is covered under Cigna's medical benefit (not pharmacy benefit) and requires administration through their specialty network. Check your member ID card or call (800) 88-CIGNA to verify:

Formulary Status

As of 2024, Exondys 51 requires prior authorization under Cigna's medical necessity criteria. The drug must be administered by a Cigna Pathwell Specialty Network provider for coverage.

What You Need to Gather

Essential Documentation Checklist

Patient Information:

  • Cigna member ID and policy details
  • Current weight (for 30 mg/kg dosing calculation)
  • Complete contact information

Clinical Requirements:

  • Genetic testing: CLIA-certified lab report confirming pathogenic DMD gene variant amenable to exon 51 skipping
  • 6-minute walk test: Must show ≥180 meters walked independently
  • Specialist prescription: From neurologist, neuromuscular specialist, or MDA clinic physician
  • ICD-10 code: G71.01 (Duchenne or Becker muscular dystrophy)

Baseline Assessments (within 30 days):

  • Cardiac function: LVEF >40% via echocardiogram
  • Pulmonary function: FVC ≥50% predicted
  • Kidney function: Normal BUN/creatinine, urinalysis
Tip: Gather all documents before starting your PA request. Missing items are the most common reason for delays or denials.

Submit Your Prior Authorization

Step-by-Step Submission Process

1. Choose Your Submission Method

  • Online: CoverMyMeds portal (recommended)
  • Fax: (855) 840-1678
  • Phone: (800) 882-4462 for urgent requests

2. Complete the CCRD Form Use Cigna's "Amondys 45/Exondys 51/Viltepso/Vyondys 53" form or the Exondys 51-specific PSC form. Required fields include:

  • Patient demographics and Cigna ID
  • Prescriber DEA, NPI, and contact information
  • Drug details: specify 100mg/2mL or 500mg/10mL vial
  • Administration site and frequency

3. Attach Supporting Documents

  • Genetic test results
  • 6MWT results
  • Specialist consultation notes
  • Baseline cardiac and pulmonary function tests
  • Prior therapy documentation (if applicable)

4. Specify Administration Details Indicate preferred specialty pharmacy:

  • Accredo (Cigna's preferred): 1-866-759-1557
  • Alternative: Orsini or approved home infusion provider

Follow-Up and Timelines

Standard Processing Times

  • Standard review: 5 business days
  • Expedited review: 72 hours (requires clinical justification)
  • Status check: CoverMyMeds portal or call (800) 882-4462

When to Follow Up

Call Cigna if you haven't received a decision within:

  • 7 days for standard requests
  • 3 days for expedited requests

Sample Follow-Up Script: "I'm calling about prior authorization request #[reference number] for Exondys 51 for [patient name], member ID [number]. Can you provide a status update and expected decision date?"

If You're Asked for More Information

Common Additional Requests

Medical Necessity Questions:

  • Provide detailed clinical rationale from specialist
  • Include FDA labeling information
  • Attach relevant treatment guidelines

Genetic Testing Clarification:

  • Ensure lab report specifically mentions "exon 51-skipping amenable"
  • Include CLIA certification of testing laboratory

Functional Assessment:

  • Submit complete 6MWT report with distance and time
  • Document patient's current ambulatory status
Note: Respond to information requests within the timeframe specified (typically 14 days) to avoid automatic denial.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason Solution
Missing genetic confirmation Submit CLIA-certified genetic test showing exon 51 amenability
Non-specialist prescriber Obtain consultation/prescription from neurologist or MDA clinic
Insufficient ambulatory function Provide 6MWT showing ≥180m independent walking
Missing baseline assessments Submit cardiac (LVEF >40%) and pulmonary (FVC ≥50%) tests

Request a Peer-to-Peer Review

Before filing a formal appeal, request a peer-to-peer discussion between your prescriber and Cigna's medical director. This often resolves denials quickly.

Appeals Process in Texas

Internal Appeals (Required First Step)

Level 1 Appeal

  • Timeline: File within 180 days of denial
  • Decision time: 30 days (standard), 72 hours (expedited)
  • How to file: Cigna member portal, mail, or fax
  • Include: Denial letter, medical records, physician support letter

Level 2 Appeal

  • Timeline: File within 60 days of Level 1 denial
  • Decision time: 30 days
  • Process: Similar to Level 1 with additional clinical evidence

Texas External Review (IRO)

If both internal appeals are denied, you can request free external review:

  • Timeline: Request within 4 months of final internal denial
  • Decision time: 20 days (standard), 5 days (expedited)
  • Cost: Free to patient (Cigna pays IRO fees)
  • Contact: Texas Department of Insurance at 1-800-252-3439
  • Outcome: Binding decision on Cigna
Texas Advantage: The state's IRO process is particularly strong for specialty drug appeals, with decisions binding on insurers.

Renewal and Reauthorization

Continuation Criteria (Every 6 Months)

Required Documentation:

  • Continued specialist oversight
  • Stable or improved functional assessments
  • Updated cardiac and pulmonary function tests
  • Evidence of clinical benefit or disease stability

Timeline for Renewal: Submit reauthorization 30-45 days before current approval expires to avoid treatment interruption.

Cost Assistance Options

Financial Support Programs

Sarepta Therapeutics Patient Support:

  • Connect Assist Program
  • Copay assistance for eligible patients
  • Contact: Exondys51.com

Foundation Grants:

  • Patient Advocate Foundation
  • HealthWell Foundation
  • National Organization for Rare Disorders (NORD)

Texas-Specific Resources

Contact the Texas Department of Insurance Consumer Help Line at 1-800-252-3439 for assistance with coverage disputes.

When Coverage Gets Complex

Navigating specialty drug approvals can be overwhelming, especially when dealing with rare conditions like Duchenne muscular dystrophy. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals using the right medical evidence and clinical facts that payers expect to see.

For complex cases involving multiple denials or unusual circumstances, consider working with advocacy organizations or specialized services that understand the intricacies of rare disease coverage.

Quick Reference Checklist

Before Submitting PA:

  • Verify Cigna specialty drug coverage
  • Confirm prescriber is in-network
  • Gather genetic testing (exon 51 amenable)
  • Complete 6MWT (≥180m required)
  • Obtain baseline cardiac/pulmonary tests
  • Get specialist prescription/consultation

During PA Process:

  • Submit via CoverMyMeds or fax (855) 840-1678
  • Track status in portal
  • Respond to information requests promptly
  • Request peer-to-peer if initially denied

If Denied:

  • File Level 1 appeal within 180 days
  • Include additional clinical evidence
  • Request Level 2 appeal if needed
  • File Texas IRO external review as final step

Frequently Asked Questions

How long does Cigna prior authorization take in Texas? Standard PA decisions take 5 business days, while expedited requests are processed within 72 hours when clinical urgency is documented.

What if Exondys 51 is denied for medical necessity? Request a peer-to-peer review with Cigna's medical director, then file internal appeals. Texas offers free external review through the IRO process if internal appeals fail.

Can I request expedited review? Yes, if delays would jeopardize health or cause severe pain. Document the clinical urgency in your request.

Does step therapy apply to Exondys 51? Cigna's policy doesn't specify step therapy requirements, but they may request documentation of prior treatments or corticosteroid use.

What happens if my specialist isn't in Cigna's network? You may need to obtain a consultation from an in-network neurologist or request a network exception for your current specialist.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with Texas insurance disputes, contact the Texas Department of Insurance at 1-800-252-3439.

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