By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Cigna in Washington: Complete PA Guide with Appeal Scripts

Answer Box: Getting Humira Covered by Cigna in Washington

Eligibility: Cigna covers Humira (adalimumab) as a Tier 4 specialty medication with prior authorization required. Fastest path: Try biosimilar adalimumab alternatives first (Cyltezo, Simlandi) as required by step therapy. Start today: Have your rheumatologist submit the Accredo specialty pharmacy referral form with documentation of biosimilar failures or contraindications. Appeals must be filed within 180 days of denial through Washington's robust external review system.

Table of Contents

Plan Types & Network Requirements

Cigna offers several plan types in Washington, each with different requirements for accessing Humira:

HMO Plans: Require a referral from your primary care provider before seeing a rheumatologist. Your PCP must coordinate care and approve the specialist visit.

PPO Plans: Allow direct access to in-network rheumatologists without referrals, but staying in-network minimizes costs.

EPO Plans: Function like PPOs with no referral needed, but out-of-network care (except emergencies) isn't covered.

Network Adequacy in Washington

Cigna must ensure 80% of urban members are within 30 miles of specialists, and rural members within 60 miles. If you can't find an in-network rheumatologist meeting these standards, you can request authorization for out-of-network care at in-network rates.

Tip: Use the Cigna provider directory to verify your rheumatologist's network status before scheduling.

Formulary Status & Tier Placement

Humira is placed on Tier 4 (Specialty Medications) across Cigna's formularies, requiring:

  • Prior authorization (PA)
  • Quantity limits (QL)
  • Specialty pharmacy dispensing

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Clinical documentation needed before approval Cigna PA forms
Step Therapy Must try biosimilars first Cigna formulary policy
Tier 4 Coinsurance 20-40% of drug cost Plan benefits summary
Specialty Pharmacy Must use Accredo/Express Scripts Member portal
180-day Appeal Window Deadline for challenging denials Washington state law

Prior Authorization & Step Therapy

Required Clinical Documentation

Your rheumatologist must submit:

  1. Diagnosis with ICD-10 codes for approved indications (RA, PsA, CD, UC, etc.)
  2. Disease activity scores (BASDAI ≥4 or ASDAS ≥2.1 for ankylosing spondylitis)
  3. Prior therapy failures:
    • Two NSAIDs (≥4 weeks each)
    • One DMARD like methotrexate (≥3 months)
    • Two adalimumab biosimilars (≥12 weeks each)
  4. Contraindications or intolerances to preferred agents
  5. TB/HBV screening results and infection history

Step Therapy Requirements

Cigna's biosimilar-first policy requires documented trials of:

  • Adalimumab biosimilars: Cyltezo, Simlandi, adalimumab-adaz
  • Alternative TNF inhibitors: Enbrel (etanercept), Simponi (golimumab)
  • JAK inhibitors: Xeljanz IR (for certain indications)

Exceptions require documentation of inactive ingredient allergies or specific contraindications to biosimilar formulations.

Specialty Pharmacy Setup

Accredo Enrollment Process

  1. Prescriber submits referral form via Accredo's portal or fax
  2. Insurance verification by Accredo staff
  3. Patient onboarding call for delivery logistics and injection training
  4. Ongoing pharmacy support with adherence monitoring
Note: Download the current Accredo Humira referral form from the Accredo prescriber portal. Complete all sections accurately to avoid delays.

Patient Setup Requirements

  • Complete demographic and insurance information
  • HIPAA authorization for information sharing
  • Consent for specialty pharmacy services
  • Delivery address confirmation

Cost-Share Dynamics

Tier 4 Coinsurance Structure

Most Cigna plans require coinsurance rather than fixed copays for Humira:

  • Standard range: 20-40% of negotiated drug cost
  • Deductible: May apply before coinsurance kicks in
  • Out-of-pocket maximum: Caps annual spending

Cost-Saving Options

  • Manufacturer copay assistance: AbbVie offers support for eligible patients
  • Foundation grants: Patient advocate foundations may help with copays
  • Medicare Part D: 2025 plans cap out-of-pocket costs at $2,000 annually

This is educational information only. Consult your benefits summary for exact cost-sharing details.

Appeals Process in Washington

Washington provides robust consumer protections for insurance denials through a multi-level appeals system.

Internal Appeals Timeline

  • Submission deadline: 180 calendar days from denial
  • Processing time: 60 days for standard review
  • Required documents: Appeal form, clinical records, denial letter

External Review Process

After exhausting internal appeals, Washington residents can request an Independent Review Organization (IRO) review:

  1. Request deadline: 180 days from final internal denial
  2. IRO assignment: Washington Insurance Commissioner assigns reviewer
  3. Decision timeline: 30 days (72 hours for expedited)
  4. Binding outcome: IRO decision is final and binding on Cigna

Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 for assistance with appeals.

Step-by-Step: Filing an Appeal

  1. Gather documents: Denial letter, clinical notes, treatment history
  2. Complete appeal form: Use Cigna's medical appeal form
  3. Submit within 180 days: Via member portal or fax
  4. Track status: Follow up if no response within 60 days
  5. Request external review: If internal appeal denied
  6. Contact OIC: For guidance at 1-800-562-6900

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document biosimilar failures Trial records, intolerance notes
Insufficient disease severity Provide activity scores BASDAI, ASDAS, lab results
Missing TB screening Submit screening results Chest X-ray, QuantiFERON test
Lack of prior DMARD trial Document methotrexate attempt Prescription history, failure notes
Quantity limit exceeded Justify dosing frequency Weight-based calculations, guidelines

Patient Action Scripts

Calling Cigna Member Services

"Hi, I'm calling about my Humira prior authorization. My member ID is [ID number]. Can you tell me the status and what additional documentation might be needed? I'd also like to understand the step therapy requirements and any preferred alternatives."

Requesting Peer-to-Peer Review

"This is [clinic name] requesting a peer-to-peer review for [patient name]'s Humira prior authorization. Our rheumatologist would like to discuss the medical necessity with your medical director. When is the earliest available time?"

Clinician Corner: Medical Necessity Letter Checklist

When drafting appeals, include:

  • Specific diagnosis with ICD-10 codes
  • Treatment history with dates, dosages, outcomes
  • Clinical rationale for Humira over alternatives
  • Guideline support from ACR, EULAR, or FDA labeling
  • Monitoring plan for safety and efficacy
  • Contraindications to preferred agents
From our advocates: "We've seen the strongest appeals include specific dates of prior treatments, exact reasons for discontinuation (side effects vs. lack of efficacy), and direct quotes from clinical guidelines. One successful case included a detailed explanation of why the patient couldn't tolerate the preservatives in biosimilar formulations, supported by allergy testing results."

FAQ

How long does Cigna prior authorization take in Washington? Standard reviews typically take 15-30 days. Expedited reviews for urgent cases can be completed in 24-72 hours.

What if Humira is non-formulary on my plan? Request a formulary exception with clinical justification. Document why preferred alternatives are inappropriate for your specific case.

Can I request an expedited appeal? Yes, if your health could be seriously jeopardized by delays. Contact Cigna member services to request expedited processing.

Does step therapy apply if I tried biosimilars in another state? Yes, documented trials from other providers generally satisfy step therapy requirements. Ensure records are transferred to your new rheumatologist.

How much will Humira cost with Cigna coverage? Tier 4 coinsurance typically ranges from 20-40% of the negotiated price. With manufacturer assistance, many patients pay $5-$10 per month.

What happens if my appeal is denied? You can request external review through Washington's IRO process. The state Insurance Commissioner will assign an independent reviewer whose decision is binding.

When to Contact Washington Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Cigna doesn't respond within required timeframes
  • You need help navigating the appeals process
  • You believe your denial was inappropriate
  • You want to file a complaint about claim handling

Phone: 1-800-562-6900
Website: Washington Insurance Commissioner

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, pulling the right clinical evidence and operational details payers expect. Learn more at CounterforceHealth.org.

When dealing with complex prior authorizations like Humira, having the right documentation and understanding payer-specific workflows can make the difference between approval and denial. Counterforce Health's system is designed to navigate these exact scenarios, helping ensure cleaner submissions and faster approvals.

Sources & Further Reading

This article provides educational information about insurance coverage and appeals processes. It is not medical advice. Always consult your healthcare provider about treatment decisions and your insurance company about specific coverage details. Coverage policies and requirements change frequently—verify current information with official sources.

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