By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Cigna in Texas: Appeals Guide and Medical Necessity Templates

Answer Box: Getting HyperHEP Covered by Cigna in Texas

Cigna requires prior authorization for HyperHEP (hepatitis B immune globulin) based on CDC post-exposure prophylaxis guidelines. Submit PA within 24-48 hours of exposure with documentation including incident report, source HBsAg status, and vaccination history. If denied, file Level 1 appeal within 180 days, then Level 2, then Texas Independent Review Organization (IRO) external review for binding decisions. Emergency cases can receive expedited 72-hour approval with proper medical urgency documentation.

First step today: Contact your prescriber to initiate electronic PA submission through Cigna's provider portal or call 800-753-2851 for verbal authorization.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all HyperHEP prescriptions Cigna provider portal or call 800-753-2851 Cigna PA Guidelines
Medical Necessity Must follow CDC post-exposure guidelines CDC MMWR hepatitis B recommendations CDC Guidelines
Timing Window Within 24-48 hours of exposure (optimal) FDA prescribing information HyperHEP Prescribing Info
Specialty Pharmacy Often required through Accredo Cigna specialty pharmacy network Cigna Specialty Pharmacy
Appeals Deadline 180 days from denial notice Texas insurance regulations Texas OPIC

Step-by-Step: Fastest Path to Approval

1. Document the Exposure Immediately

Who: Patient or healthcare provider
What: Create detailed incident report with date, time, type of exposure
Timeline: Within hours of exposure
Submit to: Keep for PA documentation

2. Check Patient's Hepatitis B Status

Who: Healthcare provider
What: Review vaccination records, check anti-HBs titers if available
Timeline: Same day as exposure
Submit to: Include in PA request

3. Submit Electronic Prior Authorization

Who: Prescribing physician or staff
What: Complete PA through CoverMyMeds or Cigna provider portal
Timeline: Within 24-48 hours of exposure
Expected response: 72 hours standard, 24 hours expedited

4. Include Required Documentation

Who: Healthcare provider
What: Exposure details, patient immunity status, CDC guideline references
Timeline: With initial PA submission
Submit to: Electronic PA system or fax

5. Request Peer-to-Peer if Needed

Who: Prescribing physician
What: Direct discussion with Cigna medical director
Timeline: If initial PA is questioned
Contact: Through Cigna provider services

6. Monitor PA Status

Who: Patient or provider staff
What: Check approval status via provider portal or member services
Timeline: Daily until decision
Contact: 1-800-88-CIGNA for status updates

7. Escalate if Denied

Who: Patient with provider support
What: File formal appeal within 180 days
Timeline: Immediately upon denial
Submit to: Cigna appeals department

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Outside timing window" Emphasize CDC guidelines allow up to 7 days post-exposure Incident report with exact exposure date, medical urgency letter
"Vaccination status unclear" Submit complete immunization records Vaccination history, anti-HBs titers if available
"Not medically necessary" Cite CDC post-exposure prophylaxis recommendations Source HBsAg status, patient risk factors, CDC guidelines
"Quantity limits exceeded" Justify weight-based dosing per FDA label Patient weight, FDA dosing guidelines, clinical rationale
"Preferred alternative available" Explain why HyperHEP specifically needed Comparative effectiveness data, patient-specific factors

Appeals Process for Texas Cigna Plans

Level 1 Internal Appeal

  • Deadline: 180 days from denial notice or EOB date
  • Cigna Response Time: 30 days (pre-service) or 60 days (post-service)
  • Submit to: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Required: Claim number, member ID, medical necessity documentation, physician signature

Level 2 Internal Appeal

  • Deadline: 60 days from Level 1 denial
  • Cigna Response Time: 45-60 days
  • Process: Different reviewer evaluates case
  • Enhancement: Request peer-to-peer review with medical director

Expedited Appeals

  • When to Use: Medical urgency, risk of harm from delay
  • Timeline: 72-hour decision
  • Contact: 1-800-88-CIGNA, mark submissions "EXPEDITED-URGENT"
  • Documentation: Physician attestation of urgency and potential harm

Texas Independent Review Organization (IRO)

  • Eligibility: After exhausting internal appeals for medical necessity denials
  • Timeline: 5 days (emergency), 20 days (standard)
  • Authority: Binding decision on Cigna
  • Cost: Paid by Cigna
  • Contact: Texas Department of Insurance
From Our Advocates: We've seen HyperHEP denials successfully overturned when providers include specific CDC timing guidelines and document the exact exposure circumstances. One effective strategy is submitting a brief peer-to-peer request summary alongside the formal appeal, highlighting patient-specific risk factors that make immediate treatment medically necessary.

Medical Necessity Documentation

Essential Elements for Approval

Exposure Documentation

  • Date, time, and type of exposure (needlestick, sexual, perinatal)
  • Source person's HBsAg status (if known)
  • Circumstances requiring immediate prophylaxis

Patient Status Assessment

  • Current hepatitis B vaccination history
  • Anti-HBs antibody levels (if available)
  • Immunocompromised status or other risk factors
  • Previous hepatitis B exposures or infections

Clinical Justification

  • CDC guideline references supporting treatment
  • Timing rationale (within recommended window)
  • Why alternative approaches are inappropriate
  • Expected clinical outcomes

Sample Medical Necessity Language

"Patient experienced high-risk percutaneous exposure to HBsAg-positive source on [date]. Per CDC guidelines, HyperHEP administration within 24-48 hours provides optimal post-exposure prophylaxis. Patient's vaccination status [incomplete/unknown] necessitates immediate passive immunization to prevent hepatitis B infection. Treatment aligns with FDA-approved indications and ACIP recommendations for post-exposure management."

Cost Assistance Options

Manufacturer Support

  • Grifols Patient Assistance: Contact manufacturer for potential copay assistance
  • Eligibility: Varies by insurance type and income
  • Application: Through prescribing physician or specialty pharmacy

Foundation Assistance

  • HealthWell Foundation: May cover hepatitis-related treatments
  • Patient Advocate Foundation: General prescription assistance
  • Eligibility: Income-based, disease-specific criteria

Emergency Administration

  • Hospital Financial Aid: Many Texas hospitals offer charity care
  • Emergency Medicaid: May cover emergency treatment costs
  • Application: Through hospital financial counselors

When traditional insurance coverage faces delays, Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to craft point-by-point rebuttals aligned with payer-specific requirements, potentially reducing the time between exposure and treatment approval.

When to Escalate to State Regulators

Texas Department of Insurance Complaints

File when:

  • Cigna violates Texas appeal timelines
  • Unreasonable denial of medically necessary treatment
  • Procedural violations in review process

Contact: Texas Department of Insurance
Phone: 1-800-252-3439
Required: Policy number, timeline of events, denial letters, appeal correspondence

Office of Public Insurance Counsel (OPIC)

Services: Free consumer assistance with insurance disputes
Contact: 1-877-611-6742
Website: OPIC.texas.gov
Assistance: Appeal guidance, IRO process explanation, consumer rights

FAQ: HyperHEP Coverage in Texas

How long does Cigna prior authorization take for HyperHEP?

Standard PA decisions take up to 72 hours. Expedited reviews for urgent cases can be approved within 24 hours with proper medical urgency documentation. Emergency department administration may proceed with retroactive PA approval.

What if HyperHEP is non-formulary on my Cigna plan?

Request a formulary exception through your prescriber, providing medical necessity justification. Include documentation explaining why formulary alternatives are inappropriate for post-exposure prophylaxis.

Can I request an expedited appeal in Texas?

Yes. Expedited appeals are available when delays would jeopardize health. Contact Cigna at 1-800-88-CIGNA and submit documentation marked "EXPEDITED-URGENT" with physician attestation of medical urgency.

Does step therapy apply to HyperHEP?

Step therapy typically doesn't apply to post-exposure prophylaxis due to the urgent nature of treatment. However, some plans may require documentation that active hepatitis B vaccination alone is insufficient.

What happens if I miss the 180-day appeal deadline?

Missing the deadline generally forfeits your right to internal appeals. However, extraordinary circumstances may qualify for deadline extensions. Contact Cigna immediately to discuss options.

How successful are HyperHEP appeals in Texas?

While specific statistics for HyperHEP aren't published, appeals with strong medical necessity documentation and CDC guideline support have higher success rates. External IRO reviews often favor patients when medical evidence supports treatment necessity.

Can I use any pharmacy for HyperHEP?

Cigna often requires specialty medications like HyperHEP to be dispensed through Accredo specialty pharmacy. Check your plan documents or contact member services to confirm network requirements.

What if I need HyperHEP over a weekend or holiday?

Emergency departments can administer HyperHEP for urgent post-exposure prophylaxis. Work with the ED physician to submit retroactive PA documentation as soon as possible after treatment.

For complex cases involving multiple denials or procedural challenges, Counterforce Health specializes in transforming insurance denials into successful appeals by leveraging payer-specific workflows and evidence-based documentation strategies.

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 regarding medical decisions and verify current coverage details with Cigna directly. Appeal processes and timelines may vary based on specific plan types and state regulations.

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