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

How to Get Haegarda (C1-esterase inhibitor, SC) Covered by Cigna in New York: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Haegarda Covered by Cigna in New York

Cigna requires prior authorization for Haegarda with specialist diagnosis, lab confirmation (low C4), and documented HAE attack history. Submit through your HAE specialist using Cigna's C1-esterase inhibitor PA form. If denied, you have 180 days for internal appeals and 4 months for external review through New York DFS. First step today: Confirm your HAE specialist has current labs and attack records, then request PA submission with CSL Behring copay assistance screening.

Table of Contents

  1. Coverage Requirements & Prior Authorization
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Cost-Saving Strategies
  5. Appeals Process in New York
  6. Specialty Pharmacy Coordination
  7. When Coverage Changes: Annual Renewals
  8. FAQ

Coverage Requirements & Prior Authorization

Cigna treats Haegarda as a specialty medication requiring prior authorization under their C1-esterase inhibitor policy. The drug is typically placed on a high specialty tier with significant coinsurance rather than a flat copay.

Coverage at a Glance

Requirement What it means Where to find it Source
Prior Authorization Must be approved before dispensing Cigna PA policy Cigna
Specialist Requirement Allergist/immunologist or HAE specialist Same policy Cigna
Lab Documentation Low C4 level by reference range Same policy Cigna
Age Restriction ≥6 years for prophylaxis FDA label FDA
Quantity Limits Up to 48 vials per 28 days (2000 IU) Cigna quantity policy Cigna
Specialty Pharmacy Usually required (Accredo common) Member benefits or pharmacy team Plan-specific
Note: New York residents have extended appeal rights through the state's external review program, giving you additional leverage if Cigna initially denies coverage.

Step-by-Step: Fastest Path to Approval

1. Confirm HAE Diagnosis Documentation

Who: Your HAE specialist What: Gather lab results showing low C4 and C1-esterase inhibitor deficiency, plus documented attack history Timeline: Can be done immediately if labs are current

2. Submit Prior Authorization Request

Who: HAE specialist's office What: Complete Cigna's PA form with medical necessity letter How: Fax to Cigna precertification or submit via provider portal Timeline: Decision within 72 hours (24 hours if expedited)

3. Coordinate Specialty Pharmacy

Who: Prescriber and patient What: Submit prescription to Accredo or designated specialty pharmacy using HAE referral form Timeline: Benefits verification within 24-48 hours

4. Apply for Financial Assistance

Who: Patient with pharmacy support What: Enroll in CSL Behring copay program (commercial insurance) or foundation grants How: Through HAEGARDA Connect at 1-844-423-4273 Timeline: Immediate for copay cards; varies for foundation grants

5. Schedule Training and First Shipment

Who: Patient with specialty pharmacy What: Complete injection training and coordinate delivery Timeline: Usually within 5-7 days of approval

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Key Documents
"No confirmed HAE diagnosis" Submit C1-INH functional assay and C4 levels Lab reports with reference ranges
"Prophylaxis criteria not met" Document attack frequency/severity history Attack diary, ER records, rescue med use
"Prefer oral prophylaxis first" Show berotralstat failure/intolerance or contraindication Treatment history, side effect documentation
"Not prescribed by specialist" Confirm allergist/immunologist credentials Provider CV or board certification
"Quantity exceeds limits" Justify dosing based on weight and attack control Weight-based dosing calculation, attack logs
From our advocates: We've seen denials overturned when patients provide a comprehensive attack diary spanning 6-12 months, showing both frequency and impact on daily activities. Emergency room records from breakthrough attacks while on other prophylaxis can be particularly compelling evidence.

Cost-Saving Strategies

Understanding Your Costs

Haegarda typically costs in the high four to five figures per vial before insurance. On Cigna's specialty tier, you'll likely pay coinsurance (percentage of the drug cost) rather than a flat copay.

Manufacturer Support Programs

For Commercial Insurance (Employer, ACA Plans):

  • CSL Behring copay assistance covers 100% of eligible out-of-pocket costs up to annual program limits
  • Contact Connect Programs at 888-508-6978
  • Eligibility: US residents with commercial insurance that covers Haegarda

For Medicare/Medicaid:

  • Federal law prohibits manufacturer copay assistance
  • CSL Behring may offer free drug programs for qualifying patients
  • Must be structured as donations, not copay help

Independent Foundation Grants

The Assistance Fund - HAE Program:

  • Covers copays, coinsurance, and deductibles for FDA-approved HAE treatments
  • Includes premium assistance and incidental medical costs
  • Application process
  • Often has waiting lists; enroll even when closed

US HAEA Support:

  • Call Health Advocates at 877-839-4232 for current foundation availability
  • Provides navigation for all financial assistance options
  • Tracks real-time funding status across programs

Specialty Pharmacy Financial Coordination

Many specialty pharmacies actively pursue grants on your behalf:

  • Accredo: Dedicated HAE team with 24/7 support
  • LeMed Specialty: Actively finds copay assistance for HAE patients
  • Ask your pharmacy to screen for all available programs simultaneously

Appeals Process in New York

New York provides robust appeal rights that exceed federal minimums, giving you multiple paths to overturn Cigna denials.

Internal Appeals (Required First Step)

Deadline: 180 days from denial notice Where to file: Cigna National Appeals Unit, PO Box 188011, Chattanooga, TN 37422 Timeline: 30 days for standard review, 72 hours for expedited Success rate: 70-78% when supported by strong medical evidence

Peer-to-Peer Review

Before formal appeals, request a peer-to-peer review where your HAE specialist speaks directly with Cigna's medical director. This informal process has an 80-85% success rate for prior authorization denials.

External Review Through New York DFS

If internal appeals fail, New York's external review provides binding decisions from independent medical experts.

Key advantages:

  • 4-month deadline from final internal denial (longer than federal requirements)
  • Expedited review: 72 hours for urgent cases
  • High success rate: 55-61% for specialty drugs
  • Binding decision: Cigna must comply with approvals
  • Low cost: Maximum $25 fee, waived for financial hardship

How to file:

  1. Complete internal appeals first
  2. Submit request via DFS online portal or mail
  3. Include denial letters, medical records, and supporting literature
  4. DFS assigns independent reviewer within specialty area
Tip: New York's external review database includes past decisions with medical literature citations. Search similar cases to strengthen your appeal strategy.

When to Request Expedited Review

  • Delay would seriously jeopardize health
  • Breakthrough HAE attacks occurring
  • Current prophylaxis failing or causing severe side effects
  • Timeline: 24 hours for urgent drug denials

Specialty Pharmacy Coordination

Counterforce Health helps patients navigate complex specialty drug approvals by turning insurance denials into targeted, evidence-backed appeals. Their platform identifies denial reasons and drafts point-by-point rebuttals using payer-specific policies and clinical evidence.

Working with Accredo (Common Cigna Specialty Pharmacy)

Accredo typically handles Haegarda dispensing for Cigna members and provides:

  • Benefits verification confirming PA status and tier placement
  • Injection training via nurse support team
  • Refill coordination with automatic shipment scheduling
  • Financial assistance screening and enrollment

Prescription Requirements for Specialty Pharmacy

Your HAE specialist should specify:

  • Exact dose in IU (typically 60 IU/kg twice weekly)
  • "Dispense: ___ doses. Keep at least ___ doses on hand"
  • "Refill x 1 year" for ongoing prophylaxis
  • Patient weight for proper vial selection

Managing Shipments and Storage

  • Coordinate delivery timing to maintain continuous supply
  • Ensure proper refrigeration during transport
  • Plan for travel needs and backup supplies
  • Set up automatic refill reminders

When Coverage Changes: Annual Renewals

Plan Year Transitions

October-November: Review Cigna's formulary changes for the coming year December: Confirm Haegarda remains covered at current tier January: Resubmit PA if required by new plan year policies

What Can Change

  • Formulary tier placement and cost-sharing
  • Prior authorization requirements
  • Quantity limits or step therapy protocols
  • Preferred specialty pharmacy networks

Proactive Steps

  1. Review annual notices from Cigna about formulary changes
  2. Maintain current labs and specialist relationship
  3. Document ongoing effectiveness with attack logs
  4. Renew financial assistance programs annually
Note: Counterforce Health's platform tracks payer policy changes and can alert you to potential coverage disruptions before they affect your therapy.

FAQ

How long does Cigna prior authorization take for Haegarda in New York? Standard review is completed within 72 hours, expedited within 24 hours if urgency is documented. Your HAE specialist can request expedited review if delays would jeopardize your health.

What if Haegarda is non-formulary on my Cigna plan? You can request a formulary exception with medical necessity documentation. New York law prohibits fail-first requirements if you've already failed formulary alternatives outside the state.

Can I use manufacturer copay assistance with Cigna? Yes, if you have commercial Cigna coverage (not Medicare or Medicaid). The CSL Behring program covers 100% of eligible out-of-pocket costs up to annual limits.

Does step therapy apply if I failed other HAE drugs outside New York? Prior treatment failures from other states count toward step therapy requirements when properly documented. Provide records showing dates, dosages, and reasons for discontinuation.

What happens if I'm denied after internal appeals? New York residents can file for external review through DFS within 4 months. This binding process has a 55-61% success rate for specialty drugs and costs maximum $25.

How do I find an HAE specialist in New York? Contact the US HAEA for specialist referrals or ask your current allergist for HAE-experienced colleagues. Cigna requires specialist involvement for approval.

Can I switch specialty pharmacies if having issues? Yes, but coordinate with your prescriber to transfer the prescription and notify Cigna of the change. Some specialty pharmacies have better financial assistance programs.

What if my attacks increase while waiting for approval? Contact your HAE specialist immediately for rescue medications (icatibant, C1-INH for acute treatment). Document breakthrough attacks as evidence for expedited review or appeals.

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 additional help with insurance appeals and coverage decisions, consider consulting with healthcare advocates or legal professionals specializing in insurance matters.

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