By Counterforce Health Team in Firazyr (icatibant injection) —

How to Get Firazyr (Icatibant) Covered by Cigna in Washington: Appeals Process, Forms, and State Protections

Quick Answer: Getting Firazyr (Icatibant) Covered by Cigna in Washington

Firazyr (icatibant) requires prior authorization from Cigna, typically managed through Express Scripts/Accredo. If denied, Washington residents have strong appeal rights: internal appeals within 180 days, followed by binding external review through an Independent Review Organization (IRO) within 120 days. Start with your prescriber submitting a PA request with HAE diagnosis confirmation, attack history, and medical necessity documentation. If denied, call Cigna at 800-882-4462 for peer-to-peer review before appealing. Contact Washington's Office of the Insurance Commissioner at 800-562-6900 for assistance.

Table of Contents

  1. Why Washington State Rules Matter
  2. Prior Authorization Requirements
  3. Step Therapy and Medical Exceptions
  4. Appeals Process: Internal and External Review
  5. Practical Scripts and Documentation
  6. Costs and Patient Assistance
  7. When to Contact State Regulators
  8. FAQ

Why Washington State Rules Matter

Washington provides some of the strongest consumer protections in the nation for insurance denials. Under RCW 48.43.535, you have the right to independent external review by medical specialists—and their decision is binding on Cigna.

This matters because Cigna's overall denial rate runs around 21%, with Medicare Advantage members appealing PA denials at rates near 18%. Many of these denials get overturned when proper evidence is presented, especially for rare diseases like hereditary angioedema (HAE).

Key protections in Washington:

Note: If your Cigna plan is self-funded through an employer (ERISA plan), federal rules apply instead of Washington state protections. Check your benefits summary or call Cigna to confirm your plan type.

Prior Authorization Requirements

Firazyr (icatibant injection) is typically non-preferred on Cigna's formulary, requiring prior authorization through Express Scripts or Accredo. At roughly $11,147 per 30mg syringe, insurers scrutinize these requests carefully.

Coverage at a Glance

Requirement What It Means Documentation Needed
HAE Diagnosis Confirmed hereditary angioedema Lab results: low C4, low C1-INH levels, normal C1q
Attack History Documented acute episodes Attack diary, emergency visits, prior treatments
Self-Administration Training Patient education completed Training certification from prescriber
Quantity Limits Typically 2-3 syringes per month Justification for frequency based on attack patterns
Medical Necessity Why Firazyr vs. alternatives Prior therapy failures, contraindications

Common denial reasons:

  • Insufficient HAE documentation
  • Request for prophylactic use (Firazyr is for acute attacks only)
  • Exceeding quantity limits without justification
  • Lack of self-administration training documentation

Step Therapy and Medical Exceptions

Cigna may require you to try other HAE treatments first, such as:

  • Generic icatibant (if available)
  • C1-INH concentrates (Berinert, Ruconest)
  • Ecallantide (Kalbitor)

To bypass step therapy, your prescriber must document why alternatives are inappropriate:

  • Previous treatment failure with specific details
  • Contraindications or adverse reactions
  • Patient-specific factors (weight, access to IV infusion)
  • Urgent need for self-injectable option

Counterforce Health helps clinicians build evidence-backed appeals that address these specific step therapy requirements, turning denials into targeted rebuttals using the plan's own criteria.

Appeals Process: Internal and External Review

Step 1: Internal Appeal (Required First)

Timeline: Within 180 days of denial notice Review time: 30 days standard, 72 hours expedited How to file: Written request to Cigna appeals department

Include in your appeal:

  • Original denial letter
  • Prescriber's medical necessity letter
  • HAE lab results and genetic testing (if available)
  • Attack diary showing frequency and severity
  • Documentation of failed alternative treatments
  • Self-administration training completion

Step 2: External Review (Binding on Cigna)

If the internal appeal fails, Washington's external review process under RCW 48.43.535 provides a powerful second chance.

Timeline: Within 120 days of final internal denial Review time: 15-20 days standard, 72 hours expedited Cost: Free to you Decision: Binding on Cigna

Step Action Timeline
File Request Submit to Cigna or OIC 120 days from final denial
Case Assignment Cigna sends records to IRO 3 business days
Your Input Submit additional evidence to IRO 5 business days
IRO Decision Independent medical review 15-20 days

To file external review:

Practical Scripts and Documentation

Patient Phone Script for Cigna

"Hi, I'm calling about a prior authorization denial for Firazyr for hereditary angioedema. My reference number is [X]. I'd like to request a peer-to-peer review with my prescriber and also understand the specific clinical criteria that weren't met. Can you connect me with someone who can schedule that and send me the detailed denial reason?"

Medical Necessity Letter Checklist

For prescribers documenting medical necessity:

✓ HAE diagnosis confirmation: Include ICD-10 code D84.1, lab values (C4, C1-INH antigenic and functional levels), family history
✓ Attack patterns: Frequency, severity, anatomical locations (laryngeal, abdominal, peripheral)
✓ Prior treatment history: Specific medications tried, dates, outcomes, reasons for discontinuation
✓ Contraindications: Why alternatives like IV C1-INH aren't suitable
✓ Self-administration rationale: Patient's ability to recognize attacks and inject promptly
✓ Monitoring plan: Follow-up schedule, emergency protocols

From our advocates: We've seen HAE appeals succeed when prescribers include specific attack logs with dates, locations affected, and duration. One common winning argument: documenting why rapid self-injection is medically necessary compared to seeking emergency care for IV treatments, especially for patients in rural areas or with a history of laryngeal involvement.

Costs and Patient Assistance

Even with insurance approval, Firazyr can have significant copays. Explore these options:

Manufacturer support:

Specialty pharmacy:

  • Accredo often handles Cigna specialty drugs
  • May offer payment plans or financial counseling

Foundation assistance:

When to Contact State Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Cigna violates appeal deadlines
  • You need help understanding your rights
  • The external review process isn't working properly
  • You suspect unfair claim practices

OIC Consumer Advocacy: 800-562-6900, 8am-5pm, Monday-Friday

The OIC can investigate violations and provide personalized guidance for complex cases. They're particularly helpful for rare disease denials where specialized medical knowledge is crucial.

Counterforce Health's platform streamlines this entire process by analyzing denial letters, identifying specific appeal strategies, and generating evidence-backed rebuttals that cite the right medical literature and payer policies—turning what could be a months-long battle into a targeted, efficient appeal.

FAQ

How long does Cigna prior authorization take for Firazyr in Washington?
Standard PA requests: 72 hours through Express Scripts/Accredo. Washington law requires 5 calendar days maximum for standard requests, 72 hours for expedited.

What if Firazyr is non-formulary on my Cigna plan?
Request a formulary exception with medical necessity documentation. Your prescriber must show why formulary alternatives are inappropriate.

Can I get expedited review for HAE attacks?
Yes. If you're currently experiencing attacks or at immediate risk, request expedited review. Washington requires 72-hour decisions for urgent cases.

Does step therapy apply if I tried alternatives outside Washington?
Yes, document all prior treatments regardless of location. Include medical records, dates, outcomes, and reasons for discontinuation.

What happens if my external review is denied?
The IRO decision is final and binding. However, you can contact the OIC if you believe the process was mishandled, or consider legal consultation for complex cases.

How much does external review cost in Washington?
External review is free to patients under RCW 48.43.535. Cigna pays the IRO fees.

Can I appeal while starting treatment?
For urgent HAE attacks, seek emergency care immediately. You can pursue appeals simultaneously. Washington's continuity of care laws may provide temporary coverage during transitions.

What if my employer plan is self-funded?
Self-funded ERISA plans follow federal rules, not Washington state protections. However, many voluntarily use similar processes. Contact the U.S. Department of Labor for ERISA plan appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with appeals, contact the Washington Office of the Insurance Commissioner at 800-562-6900.

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