By Counterforce Health Team in Keytruda (pembrolizumab) —

How to Get Keytruda (Pembrolizumab) Covered by Cigna in Pennsylvania: Complete Forms, Appeals, and Contact Guide

Quick Answer: Getting Keytruda Covered by Cigna in Pennsylvania

To get Keytruda (pembrolizumab) covered by Cigna in Pennsylvania, you'll need prior authorization through electronic portals like CoverMyMeds or ExpressPAth. Your doctor must document medical necessity, including required biomarkers (PD-L1, MSI-H, or TMB-H depending on cancer type). If denied, you can appeal internally with Cigna, then request an external review through Pennsylvania's Insurance Department within four months. Pennsylvania's external review program has overturned about 50% of appealed denials in its first year.

Table of Contents

Start Here: Verify Your Plan and Find the Right Forms

Before requesting Keytruda coverage, confirm your specific Cigna plan details:

  1. Check your insurance card for your member ID and plan type (commercial, Medicare Advantage, etc.)
  2. Log into myCigna portal to verify Keytruda's formulary status and any restrictions
  3. Identify your specialty pharmacy - most Cigna plans use Accredo for specialty drugs like Keytruda
Note: Keytruda costs approximately $23,591 per six-week dose, making proper authorization crucial for affordability.

Prior Authorization Forms and Requirements

Medical Necessity Criteria

Cigna requires specific documentation for Keytruda approval:

  • Biomarker testing results (PD-L1 expression, MSI-H/dMMR, or TMB-H status depending on cancer type)
  • Diagnosis confirmation with appropriate ICD-10 codes
  • Prior therapy documentation showing failed treatments or contraindications
  • Staging information and pathology reports
  • Treatment plan with dosing schedule and monitoring

Required Forms

Your oncologist must complete Cigna's Keytruda Prior Authorization Form, which includes:

  • Patient demographics and insurance information
  • Complete diagnosis and staging details
  • Previous treatment history and outcomes
  • Clinical justification for Keytruda therapy
  • Required biomarker test results

Electronic Submission Portals

Primary Electronic Options

CoverMyMeds (Preferred Method)

ExpressPAth

  • Accredo and Express Scripts portal
  • Real-time submissions and renewals
  • Appeals processing capability

Surescripts CompletEPA

  • Direct EHR integration
  • Submit without leaving your medical record system
  • Automatic form population

Processing Times

  • Electronic submissions: 5 business days standard
  • Expedited reviews: 24-72 hours for urgent cases
  • Incomplete submissions: May cause delays of 7-10 additional days

Fax Numbers and Mail Addresses

Key Fax Numbers for Pennsylvania

Purpose Fax Number
Keytruda Prior Authorization 855-840-1678
Prescription Transfer to Accredo 888-302-1028
Appeals and Exceptions (Use number on denial letter)

Fax Submission Tips

  • Include complete cover sheet with patient name, Cigna ID, and prescriber information
  • Send during business hours for fastest processing
  • Keep fax confirmation receipts
  • Follow up within 2-3 business days if no acknowledgment received

Specialty Pharmacy Setup (Accredo)

Most Cigna plans require Keytruda to be dispensed through Accredo specialty pharmacy.

Enrollment Process

  1. Prescriber submits PA approval and prescription to Accredo
  2. Patient enrollment via phone or online portal
  3. Insurance verification and copay determination
  4. Delivery coordination for infusion site or home delivery
  5. Ongoing support for refills and insurance issues

Accredo Contact Information

Service Phone Number
Prescription Status/Enrollment 866-759-1557
General Support 800-882-4462
Provider Services 800-803-2523

Support Phone Numbers

For Patients

  • Cigna Customer Service: Number on your insurance ID card
  • Specialty Pharmacy (Accredo): 866-759-1557
  • Prior Authorization Status: 800-882-4462

For Providers

  • Provider Services: 800-882-4462
  • Peer-to-Peer Reviews: Request through provider portal or customer service
  • Urgent Prior Authorization: 800-882-4462 (specify urgent/expedited)

Appeals Process in Pennsylvania

Internal Appeals with Cigna

Step 1: First-Level Internal Appeal

  • Timeline: File within 180 days of denial
  • Process: Submit written appeal with additional documentation
  • Response time: 72 hours standard, 24 hours expedited
  • Required: Copy of denial letter, medical records, physician statement

Step 2: Second-Level Internal Appeal

  • Timeline: 60 days after first-level denial
  • Review: Independent medical reviewers
  • Response time: 30 days standard, 72 hours expedited

When to Request Expedited Review

Request expedited internal appeals when:

  • Treatment delay could seriously jeopardize your health
  • Current therapy is failing and immediate alternative needed
  • Cancer progression documented

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each insurer's specific requirements, helping patients navigate complex prior authorization processes more effectively.

Pennsylvania External Review Program

Pennsylvania launched its Independent External Review Program in January 2024, providing state-supervised appeals after internal denials.

Eligibility and Process

Eligibility Requirements:

  • Completed all internal Cigna appeals
  • Received Final Adverse Benefit Determination letter
  • Medical necessity or coverage denial (not just billing disputes)

Submission Methods:

External Review Timeline

Review Type Initial Processing Decision Timeline
Standard Review 5 business days eligibility check 45 days from assignment
Expedited Review 24 hours eligibility check 72 hours from assignment

Success Rate: Pennsylvania reported approximately 50% of external appeals were overturned in the program's first year, resulting in coverage for previously denied treatments.

Required Documentation

  • Final denial letter from Cigna
  • All internal appeal correspondence
  • Complete medical records
  • Physician statements supporting medical necessity
  • Any additional clinical evidence

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing biomarker testing Obtain required PD-L1/MSI-H testing FDA-approved companion diagnostic results
Wrong line of therapy Document prior treatment failures Treatment history with dates and outcomes
Off-label indication Provide clinical evidence Peer-reviewed studies, guidelines
Insufficient medical necessity Submit comprehensive clinical rationale Complete medical records, specialist letters
Quantity limits exceeded Request quantity limit exception Dosing justification based on weight/BSA

Medical Necessity Letter Checklist

Your oncologist's appeal should include:

  • Current diagnosis with staging and prognosis
  • Previous treatments tried with specific outcomes
  • Clinical rationale for Keytruda based on guidelines
  • Biomarker results supporting therapy choice
  • Treatment goals and expected outcomes
  • Monitoring plan for safety and efficacy

Cost Assistance Options

Manufacturer Support

  • Merck Access Program: Financial assistance for eligible patients
  • Copay cards: May reduce out-of-pocket costs for commercially insured patients
  • Patient assistance programs: Free drug for qualifying uninsured/underinsured patients

Foundation Grants

  • Patient Advocate Foundation: Copay relief programs
  • CancerCare: Financial assistance for treatment-related costs
  • Leukemia & Lymphoma Society: Patient aid programs

State Programs

Pennsylvania residents may qualify for additional assistance through state pharmaceutical assistance programs for Medicare beneficiaries.

For patients and clinicians navigating complex coverage decisions, Counterforce Health helps streamline the appeals process by analyzing denial reasons and crafting targeted responses that align with specific payer requirements and clinical evidence.

FAQ

How long does Cigna prior authorization take for Keytruda in Pennsylvania? Standard electronic submissions typically receive responses within 5 business days. Expedited reviews for urgent medical situations are processed within 24-72 hours.

What if Keytruda is not on my Cigna formulary? Your doctor can request a formulary exception by documenting that formulary alternatives are ineffective or medically inappropriate. Submit the Pennsylvania-specific formulary exception form with clinical justification.

Can I appeal if my initial prior authorization is denied? Yes. You have 180 days to file an internal appeal with Cigna, followed by Pennsylvania's external review program if the internal appeal is unsuccessful.

What biomarker testing is required for Keytruda coverage? Requirements vary by cancer type. Common requirements include PD-L1 expression testing, MSI-H/dMMR status, or TMB-H testing using FDA-approved companion diagnostics.

Does step therapy apply to Keytruda in Pennsylvania? Step therapy requirements depend on your specific plan and cancer indication. Your oncologist can request step therapy exceptions if standard treatments are inappropriate.

How do I transfer my Keytruda prescription to Accredo? Your prescriber can fax the prescription to 888-302-1028 or call 866-759-1557. Accredo will handle insurance verification and coordinate with your infusion center.

What happens if Pennsylvania's external review overturns my denial? Cigna must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal process.

Are there income limits for manufacturer assistance programs? Yes, most programs have income eligibility requirements. Contact Merck Access Program directly to determine qualification criteria.

From our advocates: We've seen cases where initial Keytruda denials were overturned simply by providing the correct biomarker testing results that weren't included in the original submission. Always ensure your oncologist includes all required companion diagnostic results with the initial prior authorization request.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and should not replace professional medical or legal advice. Coverage policies may vary by plan and change over time. Always verify current requirements with Cigna and consult with your healthcare team for personalized guidance. For additional assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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