By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (Amifampridine) Covered by Cigna in Michigan: Complete Prior Authorization Guide

Answer Box

Getting Firdapse (amifampridine) covered by Cigna in Michigan requires prior authorization with specific LEMS diagnostic proof. Michigan residents have strong appeal rights through DIFS external review within 127 days of denial. Fastest path: (1) Have your neurologist complete Cigna's PA form with EMG/antibody results, (2) Submit via EviCore portal within 72 hours for urgent cases, (3) If denied, file internal appeal within 180 days citing medical necessity. Start with Cigna's amifampridine policy.

Table of Contents

Who Should Use This Guide

This guide helps Michigan residents with Lambert-Eaton myasthenic syndrome (LEMS) get Firdapse covered through Cigna plans—whether commercial, Medicare Advantage, or standalone Part D. You'll need this if you've received a denial, are preparing a first-time prior authorization, or want to avoid common pitfalls that delay approval.

Expected outcome: With proper documentation, most LEMS patients eventually get approved, though initial denials are common. Michigan's 127-day external review window gives you more time than federal standards to build your case.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all Cigna plans Cigna PA Policy
Age Requirement ≥6 years old FDA labeling
Prescriber Neurologist or neuromuscular specialist Cigna PA criteria
Diagnosis Proof EMG or VGCC antibodies required Cigna PA criteria
Formulary Status Specialty Tier (Tier 4/5) Cigna Formularies
Internal Appeal Deadline 180 days from denial Cigna member materials
Michigan External Review 127 days after final denial Michigan DIFS

Clinical Requirements

FDA-Approved Indication

Firdapse is approved for LEMS in adults and pediatric patients ≥6 years. Cigna requires confirmation that your diagnosis fits this exact indication—off-label uses are typically denied.

Diagnostic Documentation Needed

Your neurologist must provide at least one of these:

  • Electrodiagnostic study showing ≥60% compound muscle action potential (CMAP) increment after exercise or high-frequency stimulation
  • Positive P/Q-type voltage-gated calcium channel (VGCC) antibodies
  • Clinical presentation consistent with LEMS plus exclusion of other causes

Safety Screening

Cigna requires documentation that you have:

  • No history of seizures (absolute contraindication)
  • Appropriate renal/hepatic function for safe dosing
  • Daily dose ≤100 mg (current FDA maximum)
Clinician Corner: The PA approval hinges on clear LEMS diagnosis documentation. Include specific EMG findings (e.g., "repetitive nerve stimulation showed 75% CMAP increment at 50 Hz") rather than vague statements about "neuromuscular disorder."

Documentation Packet

Required Medical Records

  1. Neurology consultation note explicitly stating "Lambert-Eaton myasthenic syndrome"
  2. EMG/nerve conduction study report with quantified findings
  3. Laboratory results (VGCC antibodies if available)
  4. Problem list showing LEMS diagnosis with appropriate ICD-10 code (typically G70.80)
  5. Medication list and seizure history documentation

Letter of Medical Necessity Components

Your neurologist should address:

  • Clinical presentation: Proximal weakness, autonomic symptoms, fatigability
  • Diagnostic workup: EMG findings, antibody results, differential diagnosis
  • Functional impact: Walking distance, falls, work/ADL limitations
  • Treatment rationale: Why Firdapse is medically necessary vs. alternatives
  • Expected outcomes: Specific functional goals and monitoring plan

When preparing appeals, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific requirements.

ICD-10 and Coding

  • Primary diagnosis: G70.80 (Other myasthenia gravis) - most commonly accepted for LEMS
  • Alternative: G70.89 (Other specified myoneural disorders) if plan specifically lists this
  • NDC: 49948-100-01 (Firdapse 10 mg tablets)
  • Billing: Pharmacy benefit (not medical/Part B)

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify active coverage - Confirm your Cigna plan covers specialty drugs and check formulary tier
  2. Complete PA form - Use EviCore by Evernorth portal for pharmacy drugs
  3. Attach documentation - Upload all required medical records and specialist letter
  4. Submit electronically - Portal submission is faster than fax (72 hours for urgent cases)
  5. Track status - Check myCigna.com or call member services for updates
  6. Prepare for specialty pharmacy - If approved, contact Accredo or assigned vendor within 48 hours
  7. Monitor renewal dates - Submit renewal PA 2-3 weeks before expiration

Submission Mechanics

  • Portal: EviCore by Evernorth (select "Pharmacy Drugs - Express Scripts Coverage")
  • Timeline: 72 hours for standard decisions, 24-48 hours if urgent with physician attestation
  • Required fields: Member ID, prescriber NPI, diagnosis codes, requested quantity/days supply
  • Common rejection causes: Missing neurologist signature, incomplete EMG report, wrong ICD-10 code

Appeals Process in Michigan

Internal Appeals (Cigna)

  • Deadline: 180 calendar days from initial denial
  • Timeline: 30 days for standard, 72 hours for expedited review
  • Submission: Via member portal, provider portal, or mail to address on denial letter
  • Required: Denial letter, additional medical evidence, physician letter addressing denial reasons

Michigan DIFS External Review

Michigan residents get 127 days (not the federal 120) to file external review after Cigna's final internal denial.

Standard Process:

  • Timeline: 30 days for decision
  • Filing: DIFS External Review form or call 877-999-6442
  • Cost: Free to patients
  • Outcome: Binding on Cigna if overturned

Expedited Process:

  • Timeline: 72 hours for decision
  • Requirements: Physician letter stating immediate health risk
  • Applies to: Pre-service denials only
From our advocates: We've seen Michigan LEMS patients succeed in external review by submitting comprehensive EMG reports, specialist letters citing FDA labeling, and documentation of functional decline without treatment. The key is addressing every reason cited in Cigna's denial letter with specific medical evidence.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documents Needed
"Diagnosis not established" Submit detailed EMG report with quantified CMAP increment Neurology note + EMG with specific findings
"Step therapy required" Document contraindications to alternatives or prior failures Medication history, adverse reaction notes
"Exceeds dose limits" Confirm dose ≤100 mg/day per current labeling Prescription showing compliant dosing
"Not medically necessary" Cite FDA approval and clinical guidelines FDA labeling, specialist letter
"Prescriber not qualified" Confirm neurologist credentials Board certification documentation

Costs & Patient Assistance

2025 Part D Changes

If you have Cigna Medicare Part D, the 2025 redesign caps your total out-of-pocket costs at $2,000 annually. After reaching this cap, you pay $0 for covered drugs for the rest of the year.

Manufacturer Support

  • Patient assistance programs may be available for uninsured or underinsured patients
  • Commercial copay cards (not usable with Medicare)
  • Contact Catalyst Pharmaceuticals or ask your specialty pharmacy about available programs

Specialty Pharmacy Coordination

Most Cigna plans require Firdapse to be dispensed through:

  • Accredo (Express Scripts specialty pharmacy)
  • Cigna Home Delivery Pharmacy
  • Other contracted specialty vendors

Confirm your assigned pharmacy and coordinate transfer after PA approval.

Checklist: Before You Start

Patient Information:

  • Cigna member ID and group number
  • Current insurance card and policy documents
  • Complete contact information for member services

Medical Documentation:

  • Neurologist consultation notes mentioning "Lambert-Eaton myasthenic syndrome"
  • EMG/nerve conduction study reports with quantified findings
  • VGCC antibody lab results (if available)
  • Current medication list and seizure history documentation
  • Prior therapy trials and outcomes

Prescriber Requirements:

  • Board-certified neurologist or neuromuscular specialist
  • Current medical license and NPI number
  • Willingness to complete PA forms and write appeal letters if needed

Practical Preparation:

  • Identify your assigned specialty pharmacy
  • Understand your plan's specialty drug cost-sharing
  • Save all denial letters and correspondence
  • Note important deadlines (180 days internal, 127 days external in Michigan)

FAQ

How long does Cigna PA take for Firdapse in Michigan? Standard decisions within 72 hours, expedited within 24-48 hours with physician urgency certification. Complex cases may take longer if additional documentation is requested.

What if Firdapse is non-formulary on my Cigna plan? You can request a formulary exception through the same PA process. Your neurologist must demonstrate medical necessity and lack of covered alternatives.

Can I request expedited appeal if my LEMS is worsening? Yes. Have your neurologist write a letter stating that delay would seriously jeopardize your health. Both Cigna internal appeals and Michigan external review offer expedited timelines.

Does step therapy apply if I failed treatments outside Michigan? Document all prior treatments regardless of where you received them. Cigna should accept out-of-state medical records showing contraindications or treatment failures.

What happens after Michigan DIFS overturns a Cigna denial? The decision is binding. Cigna must authorize coverage and typically processes the approval within 7 days of receiving DIFS notification.

How much will Firdapse cost with Cigna coverage? Costs vary by plan type and tier. For 2025 Medicare Part D, you'll pay specialty tier cost-sharing until reaching the $2,000 annual cap, then $0 for the rest of the year.

Can I use manufacturer copay cards with Cigna Medicare plans? No, federal law prohibits manufacturer copay assistance for Medicare beneficiaries. However, need-based patient assistance programs may be available.

What if my neurologist won't complete the PA paperwork? Seek referral to a neuromuscular specialist familiar with LEMS and Firdapse. Academic medical centers often have experience with rare disease PAs and appeals.

When to Get Help

If you're struggling with denials or complex appeals, consider contacting:

  • Michigan DIFS Consumer Hotline: 877-999-6442 for external review assistance
  • Medicare State Health Insurance Assistance Program (MMAP) for Part D appeals
  • Patient advocacy organizations specializing in neuromuscular diseases

For complex cases involving multiple denials, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer-specific policies and crafting evidence-backed rebuttals that address each plan's unique requirements.

Disclaimer: This guide provides general information and should not replace professional medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and consult healthcare providers for medical decisions.

Sources & Further Reading

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