By Counterforce Health Team in Firdapse (amifampridine) —

How to Get Firdapse (amifampridine) Covered by Cigna in Pennsylvania: Complete Guide to Prior Authorization and Appeals

Quick Answer: Getting Firdapse Covered by Cigna in Pennsylvania

Yes, Cigna covers Firdapse (amifampridine) with prior authorization for confirmed Lambert-Eaton Myasthenic Syndrome (LEMS) in patients ≥6 years old. Your neurologist must submit a PA request through CoverMyMeds or Cigna's provider portal with EMG results showing ≥60% CMAP increment or positive anti-P/Q-type VGCC antibodies. Standard approval takes 15 business days; expedited requests (for urgent symptoms) get 72-hour decisions. If denied, Pennsylvania's new external review process has overturned 50% of appeals in 2024. First step today: Confirm your LEMS diagnosis meets Cigna's criteria and gather required documentation with your neuromuscular specialist.

Table of Contents

Coverage Basics: Is Firdapse Covered?

Firdapse (amifampridine phosphate) is covered on Cigna formularies as a specialty medication requiring prior authorization. The drug is FDA-approved as the only treatment for Lambert-Eaton Myasthenic Syndrome (LEMS) after Ruzurgi was withdrawn from the market in 2022.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Cigna provider portal or CoverMyMeds Cigna PA Policy
Age Limit ≥6 years old FDA label and Cigna policy Cigna Coverage Policy
Specialist Required Neurologist or neuromuscular specialist PA form requirements Cigna Coverage Policy
Dose Limit ≤100 mg/day Updated FDA label Cigna Coverage Policy
Specialty Pharmacy Usually Accredo Express Scripts network Accredo Website

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm LEMS Diagnosis (Patient + Neurologist)
    • Schedule EMG/nerve conduction studies if not done
    • Order anti-P/Q-type VGCC antibody testing
    • Document no seizure history
    • Timeline: 1-2 weeks for test results
  2. Gather Required Documentation (Clinic Staff)
    • Neurology consultation notes
    • EMG report showing ≥60% CMAP increment
    • VGCC antibody results (positive preferred)
    • Prescription within dose limits
    • Timeline: 1-3 business days
  3. Submit PA Request (Prescriber)
    • Use CoverMyMeds or Cigna provider portal
    • Include all supporting documentation
    • Request expedited review if urgent symptoms
    • Timeline: Same day submission
  4. Track Status (Patient/Clinic)
    • Check myCigna app or call 1-800-835-3784
    • Follow up if no response in 10 business days
    • Timeline: 15 business days standard, 72 hours expedited
  5. Start Treatment (Patient)

Medical Necessity Criteria

Cigna's coverage policy (IP0290, effective 11/1/2024) requires ALL of the following criteria:

Initial Approval (3 months)

  • Age: ≥6 years old
  • Confirmed LEMS diagnosis via:
    • Electrodiagnostic study showing ≥60% CMAP increment post-exercise or high-frequency stimulation, OR
    • Positive anti-P/Q-type voltage-gated calcium channel antibodies
  • No seizure history (absolute contraindication)
  • Specialist involvement: Prescribed by or in consultation with neurologist/neuromuscular specialist

Renewal Approval (1 year)

  • Continuing clinical benefit per prescriber assessment
  • Examples: Improved muscle strength, mobility, or functional capacity
  • No new contraindications
Clinician Corner: Your medical necessity letter should address the triad of LEMS symptoms (proximal weakness, autonomic dysfunction, hyporeflexia), document specific EMG findings with numerical values, and explain why Firdapse is first-line therapy per FDA labeling. Include any failed supportive therapies like pyridostigmine if tried.

Timing and Urgency

Standard Timeline

  • PA submission to decision: 15 business days
  • Appeal decisions: 30 days for internal, 45 days for external review
  • Prescription fulfillment: 2-3 business days after approval

Expedited Process

Request expedited review if patient has:

  • Frequent falls due to muscle weakness
  • Respiratory muscle involvement
  • Severe functional impairment affecting daily activities

Expedited timeline: 72 hours for PA decision, 24 hours for appeal implementation

Costs and Financial Assistance

Typical Costs

  • Retail price: ~$28,800 per month (varies by dose)
  • Cigna copay: Varies by plan tier (typically specialty tier)
  • With assistance: Often $0-$2/month average

Financial Support Options

Catalyst Pathways Program (Primary assistance)

  • Copay cards reducing out-of-pocket to $0/month for eligible patients
  • Free bridge medication (up to 60 days) during insurance verification
  • Patient assistance program for uninsured/underinsured
  • Enrollment: Call 1-833-422-8259 or visit YourCatalystPathways.com

Through Accredo Specialty Pharmacy

  • Applies manufacturer copay assistance automatically when enrolled
  • Add copay card details to your Accredo account under "Payment Methods"
  • Financial counseling available
Note: Pennsylvania has no state-specific restrictions on manufacturer copay assistance programs.

Denials and Appeals

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documentation
Insufficient LEMS diagnosis Submit complete EMG report and antibody results EMG showing ≥60% CMAP increment or positive VGCC antibodies
No specialist involvement Obtain neurology consultation Letter from neurologist confirming diagnosis and need
Seizure history concern Clarify medical history Documentation of no seizure history
Exceeding dose limits Adjust prescription Prescription ≤100 mg/day

Appeals Process in Pennsylvania

Internal Appeals (Required First)

  1. First-level internal appeal
    • Deadline: 180 days from denial
    • Decision: 30 days (standard), 72 hours (expedited)
    • Submit via: Cigna provider portal or member services
  2. Second-level internal appeal (if needed)
    • Automatic if first appeal denied
    • Same timelines as first level

Pennsylvania External Review (After Internal Appeals) Pennsylvania's Independent External Review Program, launched in 2024, has achieved a 50.1% overturn rate for denied claims. This state-supervised process applies after exhausting Cigna's internal appeals.

How it works:

  • Deadline: 4 months from final internal denial
  • Cost: Free to consumers
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Success rate: ~50% of denials overturned
  • Submission: Online at pa.gov/reviewmyclaim
From our advocates: We've seen Pennsylvania external reviews succeed particularly well for rare disease medications when the submission includes comprehensive medical literature supporting first-line treatment status. The independent physicians reviewing these cases often have more specialized knowledge than initial insurance reviewers.

Renewals and Ongoing Authorization

Reauthorization Schedule

  • Initial approval: 3 months
  • Subsequent renewals: 12 months
  • Renewal requirements: Evidence of continued clinical benefit

What to Document for Renewals

  • Functional improvement measures (walking distance, grip strength, etc.)
  • Reduced falls or respiratory symptoms
  • Improved quality of life scores
  • Prescriber attestation of ongoing benefit

Timing tip: Submit renewal requests 30 days before expiration to avoid treatment gaps.

Specialty Pharmacy Requirements

Cigna typically requires Firdapse to be dispensed through their specialty pharmacy network, primarily Accredo.

What to Expect

  • Transfer process: Accredo contacts your retail pharmacy to transfer prescription
  • Delivery: 2-3 business days via overnight shipping
  • Refill reminders: Automatic outreach before medication runs out
  • Clinical support: Pharmacist consultations available

Setting Up with Accredo

  1. Prescription sent directly from prescriber after PA approval
  2. Accredo calls to verify insurance and shipping details
  3. Apply manufacturer copay assistance during first call
  4. Schedule recurring deliveries

Troubleshooting Common Issues

PA Portal Problems

  • Cigna provider portal down: Use CoverMyMeds as backup
  • Missing forms: Download latest PA forms from Cigna provider resources
  • Submission errors: Call Cigna provider services at number on portal

Communication Issues

  • No response to PA: Call Cigna at 1-800-835-3784 to check status
  • Missing documentation: Resubmit with certified mail or portal confirmation
  • Peer-to-peer requests: Available if initial PA denied; request through provider portal

Prescription Problems

  • Dose over 100mg/day: Work with neurologist to adjust within FDA limits
  • Age under 6 years: Firdapse not approved; discuss alternatives with specialist
  • Seizure history: Absolute contraindication; consider other LEMS treatments

When Counterforce Health helps patients navigate insurance denials, we've found that systematic documentation and understanding payer-specific workflows significantly improve approval rates. Our platform helps identify the exact denial reasons and creates targeted, evidence-backed appeals that speak directly to Cigna's coverage criteria.

Frequently Asked Questions

How long does Cigna PA take in Pennsylvania? Standard prior authorization takes 15 business days. Expedited requests for urgent symptoms are decided within 72 hours.

What if Firdapse is non-formulary on my plan? Firdapse appears on Cigna formularies as a specialty medication. If your specific plan excludes it, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal? Yes, if you have urgent health concerns like frequent falls or respiratory symptoms. Both internal appeals and external reviews offer expedited timelines.

Does step therapy apply to Firdapse? Cigna's policy doesn't mandate step therapy, but documenting failed alternatives like pyridostigmine may strengthen your case.

What if I'm denied after external review? External review decisions are binding on Cigna. If you disagree with the process, contact the Pennsylvania Insurance Department at 1-877-881-6388.

How do I check if my employer plan is self-funded? Self-funded plans aren't subject to Pennsylvania's external review process. Check your Summary Plan Description or ask your HR department.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For assistance with insurance appeals and prior authorization, visit www.counterforcehealth.org.

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