By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (Amifampridine) Covered by Cigna in Georgia: Complete Appeals Guide with Forms and Deadlines

Answer Box: Getting Firdapse Covered by Cigna in Georgia

Cigna requires prior authorization for Firdapse (amifampridine) in Georgia with specific documentation requirements. Your neurologist must submit a PA request confirming LEMS diagnosis via electrodiagnostic studies or antibody testing, patient age ≥6 years, no seizure history, and specialist involvement. If denied, you have 180 days for internal appeal, then 60 days for Georgia external review. Start today by having your doctor gather diagnostic test results and complete Cigna's prior authorization form through their provider portal.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna provider portal Cigna PA Policy
Age Requirement Patient must be ≥6 years old FDA labeling Express Scripts Formulary
Diagnosis Confirmed LEMS via EMG or antibodies Clinical documentation Cigna Coverage Policy
Prescriber Neurologist or neuromuscular specialist PA form requirement Cigna PA Requirements
Seizure History Must be absent (contraindication) Medical records Express Scripts Guidelines
Quantity Limit 240 tablets per 30 days maximum Formulary restrictions Cigna Formulary

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who: Your neurologist
What: Gather diagnostic test results confirming LEMS
Timeline: Before PA submission
Required: Electrodiagnostic studies (repetitive nerve stimulation) OR anti-P/Q-type voltage-gated calcium channel antibody testing

2. Complete Prior Authorization Request

Who: Prescribing physician's office
What: Submit Cigna PA form with clinical documentation
How: Through Cigna provider portal or fax
Timeline: 72 hours for standard review, 24 hours for expedited
Source: Cigna Provider Portal

3. Include Required Clinical Information

  • Confirmed LEMS diagnosis with supporting tests
  • Patient age verification (≥6 years)
  • Absence of seizure history
  • Neurologist or specialist involvement documentation
  • Medical necessity justification

4. Submit Through Proper Channel

Pharmacy Benefit: Most common pathway through Express Scripts/Accredo
Medical Benefit: Use HCPCS code J8499 with NDC when required
Billing Units: 1 tablet = 1 unit (10 mg tablets)

5. Track Your Request

Standard Review: Decision within 72 hours
Expedited Review: Decision within 24 hours for urgent cases
Follow up: Contact Cigna customer service if no response within timeframe

6. If Approved: Coordinate Dispensing

Specialty Pharmacy: Likely through Accredo or designated network
Quantity: Up to 240 tablets per 30-day supply
Refills: Typically approved for 12 months

7. If Denied: Immediately Begin Appeal Process

Internal Appeal: Must file within 180 days in Georgia
Documentation: Gather additional clinical evidence
Next Steps: See Appeals Playbook below

Clinician Corner: Medical Necessity Documentation

When submitting a Firdapse prior authorization to Cigna, your medical necessity letter should include these essential elements:

Diagnostic Confirmation Checklist

  • LEMS diagnosis statement with ICD-10 code G70.80
  • Diagnostic test results: EMG with repetitive nerve stimulation showing incremental response, OR positive anti-P/Q-type VGCC antibodies
  • Clinical presentation: Proximal muscle weakness, reduced reflexes, autonomic symptoms
  • Differential diagnosis: Rule out myasthenia gravis, botulism, other neuromuscular conditions

Patient-Specific Requirements

  • Age verification: Patient ≥6 years old
  • Seizure history screening: Explicit statement of no seizure disorder
  • Weight/dosing rationale: Planned dosing schedule within FDA limits
  • Specialist involvement: Neurologist or neuromuscular specialist consultation

Treatment Justification

  • FDA-approved indication: LEMS treatment in appropriate age group
  • Alternative therapies considered: Document trial/failure/contraindications to pyridostigmine, IVIG, or immunosuppressants if applicable
  • Expected outcomes: Functional improvement goals and monitoring plan
From our advocates: When neurologists include specific EMG findings (like the percentage improvement in compound muscle action potential after repetitive stimulation) rather than just stating "abnormal EMG," we've seen faster PA approvals. The more specific the diagnostic evidence, the stronger the medical necessity case.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient diagnostic evidence Submit complete EMG report or antibody results Electrodiagnostic studies showing incremental response
Non-specialist prescriber Obtain neurologist consultation Neurology consultation note or co-signature
Age requirement not met Verify patient age ≥6 years Birth certificate or medical record confirmation
Seizure history concern Provide seizure screening documentation Neurologist attestation of no seizure disorder
Exceeding quantity limits Justify higher dosing needs Clinical rationale for doses >80 mg/day
Not medically necessary Strengthen clinical justification Additional specialist letters, treatment failure documentation

Appeals Playbook for Georgia

Internal Appeal Process

Timeline: Must file within 180 days of denial
How to File: Written request to Cigna member services
Required Documents:

  • Original denial letter
  • Additional clinical documentation
  • Physician letter supporting medical necessity
  • Any new diagnostic information

Cigna Review Timeline:

  • Standard: 30 days
  • Expedited: 72 hours (for urgent cases)

Peer-to-Peer Review

When: Available within 5 business days of denial
Who: Your neurologist speaks directly with Cigna medical director
How: Request through Cigna provider services
Advantage: Often resolves issues without formal appeal

Georgia External Review

If internal appeals fail, Georgia law provides external review through an independent organization.

Eligibility: Denials based on medical necessity, experimental/investigational designations
Timeline: Must file within 60 days of final internal denial
Cost: Free to patients
Process: Georgia Department of Insurance external review application

Georgia DOI Contact:

External Review Timeline:

  • Standard: 30 days
  • Expedited: 72 hours for urgent cases
  • Decision is binding on Cigna
Note: Georgia allows concurrent expedited external review with internal appeals if delay could seriously jeopardize health.

Costs & Patient Assistance Programs

Estimated Costs:

  • Retail cash price: ~$28,800 per 120 tablets (monthly varies by dose)
  • With insurance: Depends on formulary tier and copay structure

Patient Assistance Options:

  • Catalyst Pharmaceuticals Patient Assistance: Contact manufacturer directly
  • Copay assistance programs: May reduce out-of-pocket costs
  • State pharmaceutical assistance: Check Georgia programs for rare diseases

Billing Information:

  • NDC: Use full 11-digit number from packaging
  • HCPCS: J8499 for medical benefit claims
  • ICD-10: G70.80 (Lambert-Eaton myasthenic syndrome, unspecified)

When to Escalate to State Regulators

Contact the Georgia Department of Insurance if:

  • Cigna fails to respond within required timeframes
  • You believe the denial violates Georgia insurance law
  • The appeals process isn't followed properly
  • You need assistance with external review

Georgia DOI Consumer Services:

  • Phone: 1-800-656-2298
  • Online complaint: File insurance complaint
  • Address: Georgia Department of Insurance, Consumer Services Division

For additional consumer assistance, Georgians for a Healthy Future provides guidance on insurance appeals and can help navigate the process.

When patients and clinicians need comprehensive support navigating insurance denials for specialty medications like Firdapse, Counterforce Health helps turn denials into targeted, evidence-backed appeals. The platform analyzes denial letters, identifies the specific basis for denial, and creates point-by-point rebuttals aligned with each payer's own rules, pulling the right clinical evidence and regulatory citations to strengthen medical necessity arguments.

FAQ: Cigna Firdapse Coverage in Georgia

How long does Cigna prior authorization take in Georgia?
Standard PA decisions are made within 72 hours of complete submission. Expedited reviews for urgent cases are completed within 24 hours.

What if Firdapse is non-formulary on my Cigna plan?
You can request a formulary exception through your physician. Submit clinical documentation showing medical necessity and why formulary alternatives won't work.

Can I request an expedited appeal in Georgia?
Yes, if delay could seriously compromise your health. Both internal appeals and external reviews offer expedited pathways with 72-hour decision timelines.

Does step therapy apply to Firdapse?
Some Cigna plans may require trial of alternatives like pyridostigmine first. Your neurologist can request a step therapy override with clinical justification.

What happens if my external review is denied?
External review decisions are final and binding. Your remaining option would be filing a complaint with Georgia DOI or seeking legal counsel.

How do I find my specific Cigna formulary requirements?
Check your plan's formulary document or call Cigna member services. Requirements can vary between commercial, Medicare, and Medicaid plans.

Can I appeal if I've moved to Georgia from another state?
Yes, but you must follow Georgia's appeal timelines and procedures. Previous state appeals don't carry over.

What if my neurologist isn't in Cigna's network?
You may need a referral to an in-network specialist or request an exception for out-of-network coverage based on lack of available specialists.

For patients facing complex denials or needing additional support with their appeals, Counterforce Health provides specialized assistance in developing comprehensive, evidence-based appeals that address payer-specific requirements and increase approval chances.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official Georgia insurance regulations and consumer rights, visit the Georgia Department of Insurance website.

Sources & Further Reading

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