By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (Amifampridine) Covered by Cigna in Florida: Complete PA Guide with Appeal Forms

Answer Box: Getting Firdapse Covered by Cigna in Florida

Cigna requires prior authorization (PA) for Firdapse (amifampridine) to treat Lambert-Eaton Myasthenic Syndrome (LEMS) in patients ≥6 years, prescribed by a neurologist or neuromuscular specialist, with confirmed diagnosis via EMG or VGCC antibody testing. Submit through Cigna's provider portal or specialty pharmacy network; standard review takes 15 business days, expedited (urgent) within 72 hours. If denied, you have 180 days to file an internal appeal, followed by external review through Florida's Department of Financial Services within 4 months.

First step today: Contact your neurologist to gather EMG results showing ≥60% CMAP increment and VGCC antibody test results, then submit PA request via Cigna portal.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Medical Necessity Documentation
  4. Common Denial Reasons & Solutions
  5. Appeals Process in Florida
  6. Billing Codes and Coverage Details
  7. Patient Scripts and Templates
  8. Cost Assistance Programs
  9. FAQ

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all Firdapse prescriptions Cigna provider portal Cigna PA policy
Age Eligibility ≥6 years old FDA label FDA approval
Prescriber Neurologist or neuromuscular specialist Cigna medical policy Cigna PA requirements
Diagnosis Confirmed LEMS via EMG or antibodies Clinical documentation ICD-10 G70.80/G70.81
Maximum Dose 100 mg/day (adults), 50 mg/day (<45 kg) Updated FDA label 2023 Firdapse prescribing info
Pharmacy Benefit Specialty pharmacy only Express Scripts/Accredo Cigna specialty network

Step-by-Step: Fastest Path to Approval

1. Confirm LEMS Diagnosis with Specialist (1-2 weeks)

Who: Your neurologist or neuromuscular specialist
Document needed: EMG showing ≥60% CMAP increment on repetitive nerve stimulation OR positive anti-P/Q-type VGCC antibodies
Timeline: Schedule within 1-2 weeks if not already done
Source: Cigna medical necessity criteria

2. Gather Required Documentation (1-3 days)

Who: Patient and clinic staff
Documents needed:

  • Neurology consultation notes
  • EMG/nerve conduction study report
  • VGCC antibody results
  • Prescription within dose limits (≤100 mg/day)
  • Confirmation of no seizure history

3. Submit Prior Authorization Request

Who: Prescriber or clinic staff
How to submit: Cigna provider portal or CoverMyMeds
Timeline: 15 business days standard, 72 hours expedited
Mark expedited if: Patient has urgent symptoms like falls or respiratory issues

4. Follow Up on PA Status

Who: Patient or clinic
When: After 7-10 business days for standard requests
Contact: Cigna provider services or member services

5. If Approved: Fill at Specialty Pharmacy

Who: Patient
Pharmacy: Express Scripts/Accredo or Cigna-designated specialty pharmacy
Timeline: 3-5 business days for delivery

6. If Denied: File Internal Appeal (within 180 days)

Who: Patient or prescriber
How: Cigna member portal, phone (1-800-Cigna24), or written appeal
Timeline: 30 days for decision (72 hours expedited)

7. If Internal Appeal Denied: Request External Review

Who: Patient
How: File with Florida Department of Financial Services
Timeline: Within 4 months of final internal denial
Contact: Florida DFS Consumer Helpline at 877-693-5236

Medical Necessity Documentation

Clinician Corner: Essential Elements for PA Success

Your medical necessity letter should include these key components:

Problem Statement:

  • Confirmed LEMS diagnosis with specific test results
  • Functional impact (muscle weakness, falls, autonomic symptoms)
  • ICD-10 code: G70.80 (LEMS unspecified) or G70.81 (LEMS in disease classified elsewhere)

Prior Treatment History:

  • Document any failed or contraindicated alternatives
  • Include pyridostigmine trials if attempted
  • Note any immunosuppressive therapy outcomes

Clinical Rationale:

  • Firdapse is the only FDA-approved amifampridine for LEMS
  • Cite FDA approval for LEMS in patients ≥6 years
  • Reference dosing within approved limits

Monitoring Plan:

  • Regular neurology follow-up
  • Functional assessment improvements
  • Safety monitoring for seizure risk
From our advocates: We've seen PA approvals come through faster when specialists include specific EMG values (like "300% CMAP increment post-exercise") rather than just stating "positive EMG." This concrete data helps reviewers quickly verify medical necessity without requesting additional documentation.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Incomplete LEMS diagnosis Submit comprehensive test results EMG with specific CMAP values, VGCC antibody titers
Non-specialist prescriber Transfer prescription to neurologist Neurology consultation note, specialist credentials
Seizure history concern Provide seizure-free documentation Neurology note confirming no seizure history/risk
Exceeding dose limits Adjust prescription to FDA limits Prescription ≤100 mg/day (adults), ≤50 mg/day (<45 kg)
Missing step therapy Document contraindications to alternatives Clinical notes explaining why pyridostigmine inappropriate

Appeals Process in Florida

Internal Appeals with Cigna

First-Level Internal Appeal:

  • Deadline: 180 days from denial notice
  • Filing methods: Cigna member portal, phone (1-800-Cigna24), or written appeal
  • Decision timeline: 30 days standard; 72 hours expedited
  • Required documents: Denial letter, additional clinical evidence, physician letter

Second-Level Internal Appeal:

  • When: After first-level denial
  • Timeline: Similar to first level
  • Note: Required before external review eligibility

External Review Through Florida DFS

Eligibility: After exhausting internal appeals for medical necessity denials
Cost: Free to patients
Timeline: 4 months from final internal denial to request; 45 days for standard decision
How to request: File with Florida Department of Financial Services
Contact: 877-693-5236 (877-MY-FL-CFO)
Success rate: Approximately 50% for specialty drug appeals with strong clinical evidence

Expedited External Review:

  • Available when delay could seriously jeopardize health
  • Physician must certify medical urgency
  • Decision within 72 hours

For assistance navigating complex appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to payer policies.

Billing Codes and Coverage Details

Primary Billing Information

Code Type Code Usage Notes
NDC 49948-100-01 10 mg tablets (primary for pharmacy claims)
HCPCS J8499 "Prescription drug, oral, non-chemotherapeutic, NOS"
ICD-10 G70.80 or G70.81 LEMS diagnosis codes

Coverage Pathway

  • Benefit type: Pharmacy benefit (not medical benefit)
  • Tier: Specialty tier (non-preferred)
  • Pharmacy network: Express Scripts/Accredo specialty pharmacies
  • Prior authorization: Required for all prescriptions

Common Billing Errors to Avoid

  • Billing under medical benefit instead of pharmacy benefit
  • Using incorrect NDC or outdated codes
  • Missing specialist attestation in claims
  • Exceeding FDA-approved dose limits

Patient Scripts and Templates

Calling Cigna Member Services Script

"Hi, I'm calling to check on the prior authorization status for my Firdapse prescription. My member ID is [ID number]. The PA was submitted on [date] for Lambert-Eaton myasthenic syndrome. Can you tell me the current status and if any additional information is needed?"

Email Template for Medical Records Request

Subject: Urgent: Medical Records Needed for Firdapse Prior Authorization

"Dear [Clinic Name],

I need the following records for my Cigna prior authorization for Firdapse:

  • EMG/nerve conduction study results
  • VGCC antibody test results
  • Neurology consultation notes
  • Documentation of no seizure history

My PA submission deadline is [date]. Please send to [fax/email] by [date].

Thank you, [Your name]"

Cost Assistance Programs

Manufacturer Support

  • Catalyst Cares Patient Assistance Program
  • Eligibility: Income-based for uninsured/underinsured patients
  • Contact: Visit Firdapse.com or call patient support

Copay Assistance

  • Commercial insurance copay cards may be available
  • Medicare patients: Not eligible for manufacturer copay assistance
  • Check eligibility: Contact Catalyst Pharmaceuticals patient support

Foundation Grants

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • Income limits and disease-specific criteria apply

Organizations like Counterforce Health can help identify additional assistance programs and ensure your applications include all required documentation for faster approval.

FAQ

Q: How long does Cigna prior authorization take for Firdapse in Florida? A: Standard PA review takes 15 business days. Expedited review (for urgent medical needs) takes 72 hours. Mark requests as expedited if the patient has urgent symptoms like frequent falls or breathing difficulties.

Q: What if Firdapse is non-formulary on my Cigna plan? A: You can request a formulary exception by demonstrating medical necessity. Include documentation that preferred alternatives are contraindicated or ineffective for LEMS treatment.

Q: Can I request an expedited appeal if my PA is denied? A: Yes, if delay in treatment could seriously jeopardize your health. Your physician must certify the urgency in writing. Expedited appeals receive decisions within 72 hours.

Q: What's the difference between G70.80 and G70.81 ICD-10 codes? A: G70.80 is for LEMS unspecified (idiopathic), while G70.81 is for LEMS secondary to another condition (like paraneoplastic LEMS associated with cancer).

Q: Does step therapy apply to Firdapse in Florida Cigna plans? A: Cigna typically doesn't require step therapy for Firdapse since it's the only FDA-approved amifampridine for LEMS. However, documenting failed alternatives like pyridostigmine can strengthen your case.

Q: What if I need more than 100 mg daily? A: The FDA-approved maximum is 100 mg/day for adults (50 mg/day for pediatric patients <45 kg). Requests above these limits will likely be denied. Work with your neurologist to optimize dosing within approved limits.

Q: Can I appeal a denial if I live in Florida but have coverage from another state? A: Yes, you follow the same Cigna internal appeal process regardless of your state of residence. However, external review rights may vary by your plan's governing state laws.

Q: How much does Firdapse cost without insurance? A: Retail prices can exceed $28,000 monthly. Patient assistance programs through Catalyst Pharmaceuticals may help reduce costs for eligible patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and appeal procedures may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For additional assistance with complex prior authorizations and appeals, consider consulting with coverage advocacy services like Counterforce Health, which specializes in helping patients navigate insurance barriers for specialty medications.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.