By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea and Lucentis Covered by Cigna in Michigan: Complete PA Guide and Appeals Process

Answer Box: Fast Track to Cigna Approval in Michigan

Getting Eylea or Lucentis covered by Cigna requires prior authorization with specific documentation. Your ophthalmologist must submit clinical notes showing wet AMD or diabetic macular edema with OCT imaging, visual acuity measurements, and evidence that lower-cost alternatives like Avastin aren't appropriate. Submit through CoverMyMeds or Cigna's provider portal. If denied, you have 180 days for internal appeals, then 127 days for Michigan DIFS external review. Most approvals come within 15 days with complete documentation.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Setup
  5. Cost-Share Dynamics
  6. Submission Process
  7. Appeals Process in Michigan
  8. Common Denial Reasons & Solutions
  9. Financial Assistance Options
  10. FAQ

Plan Types & Coverage Implications

Cigna offers several plan types in Michigan, each affecting how you access Eylea (aflibercept) and Lucentis (ranibizumab):

Commercial Plans (HMO/PPO/EPO): Most require prior authorization through Express Scripts or Accredo specialty pharmacy. PPO plans typically offer more flexibility in choosing providers, while HMO plans may require referrals to ophthalmologists.

Medicare Advantage: Subject to CMS formulary requirements with additional step therapy protocols. These plans often have stricter quantity limits and require documented failure of bevacizumab (Avastin) first.

Medicaid (Healthy Michigan): Covers anti-VEGF treatments but with extensive prior authorization requirements and preference for lower-cost alternatives.

Note: Network restrictions apply regardless of plan type. Ensure your ophthalmologist is in-network to avoid higher out-of-pocket costs.

Formulary Status & Tier Placement

Both medications are typically placed on Tier 4 or 5 (Non-Preferred/Specialty) of Cigna formularies, resulting in higher copays or coinsurance:

Drug Typical Tier Step Therapy Required Monthly Cost Range
Eylea (aflibercept) Tier 4/5 Yes (after Avastin failure) $200-$500+
Lucentis (ranibizumab) Tier 4/5 Yes (after Avastin failure) $200-$500+
Avastin (bevacizumab) Lower tier/Non-formulary First-line requirement $50-$150

Step Therapy Policy: Cigna commonly requires patients to try bevacizumab (Avastin) first unless clinical documentation supports bypassing this requirement due to contraindications or urgent medical need.

Prior Authorization Requirements

Cigna requires comprehensive documentation for anti-VEGF approval:

Medical Necessity Criteria

Required Documentation:

  • Confirmed diagnosis of wet AMD, diabetic macular edema, or other approved retinal condition
  • OCT imaging showing retinal thickening, intraretinal/subretinal fluid, or active disease
  • Visual acuity measurements (baseline BCVA documentation)
  • Evidence of functional visual impairment related to the condition
  • Treatment plan with appropriate dosing frequency

Clinical Requirements:

  • Treatment supervised by an ophthalmologist
  • Documentation of active disease requiring intervention
  • For step therapy exceptions: evidence that bevacizumab is contraindicated, previously failed, or medically inappropriate

Reauthorization Requirements

Continued coverage requires:

  • Updated OCT imaging showing persistent or recurrent disease
  • Visual acuity assessments demonstrating benefit (stabilization or improvement)
  • Clinical notes documenting ongoing medical necessity
  • Evidence that treatment goals are being met

Specialty Pharmacy Setup

Cigna typically routes anti-VEGF medications through Accredo Specialty Pharmacy:

Enrollment Process

  1. Prescription Submission: Ophthalmologist completes Accredo enrollment form with clinical data, ICD-10 codes, and insurance information
  2. Submission Methods: Fax to 888-302-1028 or submit through myaccredopatients.com
  3. Patient Contact: Accredo contacts patient within 24-48 hours to verify information and schedule delivery
  4. Insurance Verification: Accredo coordinates with Cigna for benefit verification and prior authorization

Ongoing Management

  • Cold-chain shipping at no cost to patient's home or clinic
  • 24/7 support from specialty pharmacists
  • Refill coordination and adherence monitoring
  • Assistance with copay programs and financial support

Patient Contact: 800-596-7701 for enrollment questions or delivery scheduling.

Cost-Share Dynamics

Understanding your out-of-pocket costs helps with financial planning:

Typical Cost Structure

Before Deductible: Patients pay full negotiated rate until deductible is met After Deductible:

  • Tier 4: 25-40% coinsurance
  • Tier 5: 30-50% coinsurance
  • Specialty tier: $100-$500+ copay per injection

Cost-Saving Strategies

  • Manufacturer copay cards can reduce out-of-pocket costs significantly
  • Foundation grants available for qualifying patients
  • Appeals for formulary exceptions may move drugs to preferred tiers

Submission Process

Step-by-Step Submission Guide

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete medical records with OCT imaging
    • Visual acuity measurements
    • Prior therapy documentation
  2. Complete Prior Authorization (Ophthalmologist)
    • Use CoverMyMeds for electronic submission
    • Alternative: Cigna provider portal or fax submission
    • Include all required clinical documentation
  3. Submit to Specialty Pharmacy (Clinic)
    • Complete Accredo enrollment form
    • Fax to 888-302-1028 or submit online
    • Include prescription and clinical notes
  4. Await Decision (Patient)
    • Standard review: 15 days
    • Expedited review: 72 hours (with physician urgency certification)
    • Track status through Cigna member portal

Required Forms and Documentation

  • Prior Authorization Form: Available through CoverMyMeds or Cigna provider resources
  • Clinical Documentation: OCT images, visual acuity tests, treatment history
  • Specialty Pharmacy Enrollment: Accredo-specific forms for drug dispensing

Appeals Process in Michigan

If your initial prior authorization is denied, Michigan offers robust appeal rights:

Internal Appeals (Cigna)

Timeline: Must file within 180 days of denial notice Process:

  • Submit through Cigna member portal or mail to appeals department
  • Include denial letter, additional clinical evidence, and physician attestation
  • Standard appeals decided within 30 days
  • Expedited appeals (with physician urgency certification): 24-48 hours

External Review (Michigan DIFS)

Timeline: Must file within 127 days of final internal denial Process:

Tip: Michigan's 127-day external review window is longer than the federal 120-day standard, giving you extra time to prepare a strong appeal.

Michigan DIFS Contact: 877-999-6442 for appeal process questions

Common Denial Reasons & Solutions

Denial Reason Required Documentation How to Address
Insufficient clinical documentation Complete OCT imaging, visual acuity tests Submit comprehensive clinical records with clear diagnosis
Step therapy not completed Evidence of Avastin failure/contraindication Provide documentation of prior bevacizumab trial or medical contraindication
Not meeting visual acuity criteria Current BCVA measurements Document functional visual impairment and disease activity
Quantity/frequency limits exceeded Treatment protocol justification Submit evidence-based dosing rationale with clinical guidelines
Non-formulary status Medical necessity for specific agent Request formulary exception with comparative effectiveness data

Medical Necessity Letter Checklist

Your ophthalmologist's letter should include:

  • Specific diagnosis with ICD-10 codes
  • OCT findings documenting active disease
  • Visual acuity impact on daily functioning
  • Prior treatment history and outcomes
  • Clinical rationale for chosen therapy
  • Treatment goals and monitoring plan

Financial Assistance Options

Manufacturer Programs:

Foundation Grants:

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

State Resources:

  • Michigan Department of Health and Human Services may provide additional support for qualifying residents

FAQ

How long does Cigna prior authorization take in Michigan? Standard prior authorizations are processed within 15 days. Expedited requests with physician certification of urgency are decided within 72 hours.

What if Eylea or Lucentis is non-formulary on my plan? Request a formulary exception through your ophthalmologist. Provide clinical documentation showing medical necessity for the specific agent versus formulary alternatives.

Can I request an expedited appeal in Michigan? Yes. Both Cigna internal appeals and Michigan DIFS external reviews offer expedited processes when a physician certifies that delays would jeopardize the patient's health.

Does step therapy apply if I've tried Avastin outside Michigan? Yes, but you'll need documentation from your previous provider showing the trial and outcome. Cigna accepts out-of-state clinical records for step therapy requirements.

What happens if I miss the appeal deadline? Michigan's 127-day external review window is generous, but missing it limits your options. Contact DIFS immediately to discuss potential exceptions for extraordinary circumstances.

How much will I pay out-of-pocket? Costs vary by plan design. Typical specialty tier copays range from $100-$500+ per injection. Manufacturer copay programs can significantly reduce these costs for eligible patients.

When to Contact Counterforce Health

Navigating insurance denials for costly treatments like Eylea and Lucentis can be overwhelming. Counterforce Health specializes in turning prescription drug denials into successful appeals by analyzing denial letters, identifying specific policy gaps, and crafting evidence-backed rebuttals that align with each payer's requirements.

If you've received a denial from Cigna despite meeting clinical criteria, or if you're facing complex step therapy or quantity limit challenges, professional advocacy can make the difference between approval and continued delays in accessing sight-saving treatment.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary by plan and may change. Always consult your healthcare provider for medical decisions and verify current policy details with Cigna directly.

Sources & Further Reading

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