By Counterforce Health Team in Haegarda (C1-esterase inhibitor, SC) —

How to Get Haegarda (C1-Esterase Inhibitor) Covered by Cigna in Washington: Complete Guide with Forms and Appeals Process

Answer Box: Getting Haegarda Covered by Cigna in Washington

Haegarda requires prior authorization from Cigna with documented HAE diagnosis (low C4 and C1-INH levels), specialist consultation, and clinical need for prophylaxis. Fastest path: Have your allergist/immunologist submit the PA request with lab results and attack history via Cigna's provider portal. Start today: Call your specialist to schedule labs (C4, C1-INH antigenic/functional levels) if not recent, and request they initiate the prior authorization process. Appeals follow Washington's strong external review system through certified IROs if initially denied.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Medical Necessity Criteria
  5. Cost Considerations
  6. Denials and Appeals in Washington
  7. Renewal Requirements
  8. Specialty Pharmacy Coordination
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics

Is Haegarda Covered by Cigna?

Yes, Haegarda (C1-esterase inhibitor, subcutaneous) is covered by Cigna plans but requires prior authorization. The medication is typically managed through Express Scripts/Accredo specialty pharmacy and classified as a specialty biologic requiring clinical review.

Which Cigna Plans Cover Haegarda?

  • Commercial plans: Most Cigna employer-sponsored and individual plans
  • Medicare Advantage: Covered under Part B (buy-and-bill) or Part D depending on site of care
  • Apple Health (Medicaid): Coverage varies by managed care plan; verify with Washington Apple Health at 1-877-501-2233
Note: Self-funded employer plans may have different coverage rules. Contact Cigna member services to confirm your specific plan's formulary status.

Prior Authorization Process

Who Submits the Request?

Your prescribing physician (allergist/immunologist or HAE specialist) must submit the prior authorization. Cigna requires the medication be prescribed by or in consultation with a specialist due to the complexity of HAE management.

Step-by-Step: Fastest Path to Approval

  1. Lab Confirmation (Patient/Clinic): Ensure recent labs showing low C4 and abnormal C1-INH levels
  2. Specialist Consultation (Patient): Schedule with allergist/immunologist if not already established
  3. PA Submission (Clinic): Provider submits via Cigna provider portal with required documentation
  4. Clinical Review (Cigna): 5-15 business days for standard review
  5. Training Coordination (If approved): Accredo arranges injection training through HAEGARDA ConnectSM program
  6. First Shipment (Accredo): Medication delivered with nurse training visit

Required Documentation

According to Cigna's coverage policy, submit:

  • Clinical diagnosis of HAE due to C1-INH deficiency
  • Laboratory confirmation: Lower than normal serum C4 levels
  • Chart notes documenting need for prophylaxis
  • Prescriber attestation of specialist involvement

Timing and Urgency

Standard Timeline

Step Timeframe Who Acts
PA submission Same day Clinic
Cigna review 5-15 business days Cigna
Approval notification 1-2 days Cigna to clinic
Accredo enrollment 2-3 days Specialty pharmacy
First shipment 5-7 days Accredo

Expedited Reviews

For urgent cases where delays could cause serious harm, request expedited review:

  • Timeline: 72 hours for determination
  • How to request: Physician calls Cigna at 1-800-88-CIGNA and requests urgent review
  • Documentation: Include clinical rationale for urgency (recent severe attacks, airway involvement)

Medical Necessity Criteria

Initial Therapy Requirements

Cigna requires both of the following for new patients:

  1. Clinical diagnosis: Documented hereditary angioedema (HAE) due to C1 inhibitor deficiency requiring prophylaxis
  2. Laboratory confirmation: Lower than normal serum C4 levels at baseline, as defined by laboratory reference values

HAE Diagnosis Criteria

HAE Type Lab Findings Prevalence
HAE-1 Low C4, low C1-INH antigenic level, low C1-INH function 85%
HAE-2 Low C4, normal/high C1-INH antigenic level, low C1-INH function 15%

Specialist Requirement

The medication must be prescribed by or in consultation with:

  • Allergist/immunologist, OR
  • Physician specializing in HAE or related disorders
Clinician Corner: When writing the medical necessity letter, include quantified attack frequency (baseline vs. current), severity scores, prior therapy failures, and specific clinical improvements expected with prophylaxis. Reference FDA labeling for approved indications.

Cost Considerations

Typical Coverage Structure

  • Specialty tier: Usually 25-40% coinsurance after deductible
  • Prior authorization: Required regardless of tier
  • Quantity limits: May apply based on weight-based dosing (60 IU/kg twice weekly)

Patient Support Options

  • HAEGARDA ConnectSM: Financial assistance program through CSL Behring
  • Accredo CareTeam: Specialty pharmacy support for coverage navigation
  • Washington Apple Health: Medicaid coverage with minimal copays for eligible patients

Contact HAEGARDA ConnectSM at 1-844-424-3273 for assistance with coverage verification and financial support options.

Denials and Appeals in Washington

Common Denial Reasons & Fixes

Denial Reason How to Overturn
No confirmed HAE diagnosis Submit recent lab results (C4, C1-INH levels) with specialist letter
Prophylaxis criteria not met Document attack frequency, severity, impact on quality of life
Lack of specialist involvement Obtain consultation letter from allergist/immunologist
Quantity/dosing concerns Provide weight-based dosing calculation (60 IU/kg twice weekly)

Washington Appeals Process

Washington offers strong consumer protections for insurance denials:

Internal Appeals (Required First Step)

  • Deadline: 180 days from denial notice
  • Timeline: 30-60 days for determination (72 hours if expedited)
  • How to file: Submit via Cigna member portal or mail to Cigna National Appeals, PO Box 188011, Chattanooga, TN 37422

External Review (Washington IRO)

After internal appeal denial, Washington residents can request binding external review:

From our advocates: We've seen many HAE patients successfully overturn Cigna denials in Washington by providing detailed attack logs showing frequency reduction with prophylaxis, along with specialist letters emphasizing the life-threatening nature of laryngeal attacks. The key is quantifying clinical benefit with specific data.

When to Escalate

Contact the Washington Office of Insurance Commissioner if:

  • Internal appeals are ignored or delayed beyond timelines
  • You believe the denial violates Washington insurance law
  • You need help navigating the external review process

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters and plan policies to draft point-by-point rebuttals aligned with Cigna's own coverage criteria, pulling the right citations for HAE medications and weaving them into appeals with required clinical facts. Learn more about our services.

Renewal Requirements

Continuation Therapy Criteria

For patients already receiving Haegarda, Cigna requires:

  • Currently receiving Haegarda for HAE prophylaxis
  • Medication prescribed by or in consultation with specialist
  • Continuing on same indication
  • Approval duration: 1 year

Renewal Timeline

Start renewal process 90 days before expiration:

  1. 90 days out: Clinic reviews current therapy effectiveness
  2. 60 days out: Submit renewal PA with updated clinical notes
  3. 30 days out: Follow up on pending requests
  4. 7 days out: Ensure specialty pharmacy has bridge supply if needed

Specialty Pharmacy Coordination

Accredo Partnership

Cigna typically requires Haegarda be dispensed through Accredo Specialty Pharmacy, which partners with CSL Behring's patient support program:

  • Delivery: Home shipment with temperature monitoring
  • Training: Free injection training via company-funded nurses
  • Support: 24/7 pharmacist consultation line
  • Coordination: Direct communication with prescriber for refills and adjustments

HAEGARDA ConnectSM Program

The manufacturer's support program provides:

  • Injection training: Home visits or clinic training sessions
  • Financial assistance: Copay support and insurance navigation
  • Clinical support: Dosing guidance and administration troubleshooting

To enroll, have your prescriber complete the HAEGARDA referral form and fax to 1-866-415-2162.

Troubleshooting Common Issues

Portal and System Issues

  • Cigna provider portal down: Call provider services at 1-800-88-CIGNA
  • Missing forms: Download current PA forms from Cigna provider website
  • Status updates: Check member portal or call member services

Coverage Verification Problems

  • Plan not recognizing specialty pharmacy: Verify Accredo is in-network for your specific plan
  • Dosing disputes: Provide FDA labeling showing 60 IU/kg twice weekly dosing
  • Site of care issues: Clarify home self-injection vs. clinic administration

When standard channels fail, Counterforce Health can help navigate complex coverage issues by analyzing your specific denial and plan documents to identify the most effective appeal strategy. Visit our website to learn how we turn denials into approvals.

Frequently Asked Questions

How long does Cigna prior authorization take for Haegarda in Washington? Standard review takes 5-15 business days. Expedited reviews are completed within 72 hours for urgent cases where delays could cause serious harm.

What if Haegarda is non-formulary on my plan? Request a formulary exception through your prescriber. Include medical necessity documentation showing why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal in Washington? Yes, both internal appeals and external reviews can be expedited if delays would seriously jeopardize your health. Your physician must provide clinical justification for urgency.

Does step therapy apply if I've tried other HAE medications outside Washington? Prior therapy documentation from any state is typically accepted. Provide records of failed treatments like oral kallikrein inhibitors or other C1-INH products.

What happens if my appeal is denied by Cigna? Washington residents can request binding external review through a certified Independent Review Organization (IRO). This is free and the decision is binding on Cigna if overturned.

How do I get injection training for Haegarda? Training is provided free through the HAEGARDA ConnectSM program via Accredo. A nurse will visit your home or clinic to provide hands-on training for self-injection or caregiver administration.

What if I move from Washington to another state while on Haegarda? Contact Cigna member services to ensure continued coverage. You may need to transfer to a new specialty pharmacy depending on your new location.

Can I appeal if Cigna only covers a lower dose than prescribed? Yes, quantity limit appeals can be submitted with clinical justification for the prescribed dose based on weight-based calculations (60 IU/kg twice weekly) and attack frequency.

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 guidance specific to your situation. For assistance with insurance appeals and coverage issues, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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