By Counterforce Health Team in Keytruda (pembrolizumab) —

How to Get Keytruda (Pembrolizumab) Covered by Cigna in Washington: Complete Guide to Prior Authorization, Appeals, and Cost Savings

Answer Box: Getting Keytruda Covered by Cigna in Washington

Keytruda (pembrolizumab) requires prior authorization from Cigna and is typically dispensed through their specialty pharmacy, Accredo. First step: Your oncologist submits a PA request via CoverMyMeds or SureScripts with complete clinical documentation. If denied, you have 180 days to appeal internally, then can request binding external review through Washington's Independent Review Organization. Commercial insurance patients may qualify for Merck's copay assistance (first $25 per infusion, up to $25,000/year). Contact Washington's Office of the Insurance Commissioner at 1-800-562-6900 for appeal support.

Table of Contents

  1. Understanding Your Cigna Coverage for Keytruda
  2. Prior Authorization Requirements
  3. Common Denial Reasons and How to Fix Them
  4. Cost-Saving Options and Financial Assistance
  5. Appeals Process in Washington
  6. Specialty Pharmacy Requirements
  7. Scripts and Conversation Templates
  8. When to Escalate to State Regulators
  9. FAQ

Understanding Your Cigna Coverage for Keytruda

Keytruda is classified as a specialty medication under most Cigna plans, placing it in the highest cost-sharing tier. This typically means you'll pay 20-40% coinsurance rather than a flat copay, given the drug's high cost of approximately $23,591 per six-week dose.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Cigna provider portal PA Forms
Formulary Tier Specialty (high coinsurance) Member drug list Cigna Formulary
Specialty Pharmacy Accredo preferred Cigna documentation Keytruda PA Form
Step Therapy May apply by indication Plan documents Coverage Policies
Appeals Deadline 180 days (internal) Washington state law WA Insurance Code

Prior Authorization Requirements

Your oncologist must submit a comprehensive prior authorization request that includes:

Required Clinical Documentation

  • Diagnosis with ICD-10 codes and cancer staging
  • FDA-approved indication confirmation
  • Biomarker status (PD-L1 CPS, MSI-H/TMB-H where applicable)
  • Prior therapy history including drugs tried, duration, and outcomes
  • Treatment plan with dosing schedule and monitoring
Clinician Corner: Medical necessity letters should cite specific NCCN guidelines or FDA labeling to support the indication. Include patient weight for dosing calculations and document any contraindications to alternative therapies.

Submission Process

  1. Electronic submission preferred: Use CoverMyMeds or SureScripts
  2. Alternative methods: Fax to Cigna's dedicated PA line (verify current number)
  3. Timeline: Standard review within 2 business days; expedited within 24 hours for urgent cases
  4. Follow-up: Track status through Cigna provider portal or member services

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing biomarker testing Submit lab results PD-L1 CPS, MSI-H, or TMB-H test results
Wrong line of therapy Document prior failures Treatment history with dates and outcomes
Off-label use Provide clinical rationale Peer-reviewed studies, guidelines
Incomplete staging Submit pathology reports Imaging, biopsy results, TNM staging
Quantity limits exceeded Medical necessity justification Weight-based dosing calculations

Cost-Saving Options and Financial Assistance

Merck Copay Assistance Program

Eligibility for commercial insurance patients:

  • U.S. residents with private insurance
  • FDA-approved Keytruda indication
  • Patient pays first $25 per infusion
  • Program covers up to $25,000 per year

How to enroll:

  1. Visit Merck Access Program
  2. Complete enrollment form online or by fax
  3. Call 855-257-3932 for assistance
Note: Government insurance patients (Medicare, Medicaid, VA) are not eligible for copay assistance but may qualify for separate patient assistance programs.

Additional Financial Resources

  • Merck Patient Assistance Program: For uninsured or underinsured patients
  • Cancer support foundations: Organizations like CancerCare and Patient Advocate Foundation
  • State programs: Washington Apple Health (Medicaid) expansion coverage

Appeals Process in Washington

Washington state provides robust consumer protections for insurance denials, including binding external review.

Step-by-Step Appeals Process

  1. Internal Appeal (First Level)
    • Deadline: 180 days from denial date
    • Submit to: Cigna appeals department
    • Timeline: 30 days for standard; 72 hours for urgent
    • Required: Written appeal with clinical documentation
  2. Internal Appeal (Second Level)
    • Automatic: If first level upheld
    • Timeline: Additional 30 days
    • Include: Any new clinical evidence
  3. External Review (IRO)
    • Deadline: 60-90 days after final internal denial
    • Process: Washington assigns certified Independent Review Organization
    • Timeline: 20-30 days (72 hours for urgent)
    • Outcome: Legally binding on Cigna

Required Appeal Documentation

  • Original denial letter and EOB
  • Complete medical records
  • Oncologist's medical necessity letter
  • Published clinical guidelines supporting use
  • Any new test results or clinical notes
From our advocates: A composite tip from our experience: Successful appeals often include a detailed timeline showing how the patient's condition progressed and why standard treatments failed. One effective strategy is having the oncologist reference specific NCCN guideline recommendations that support Keytruda use for the patient's exact diagnosis and stage.

Specialty Pharmacy Requirements

Cigna typically requires Keytruda to be dispensed through Accredo, their specialty pharmacy partner.

Accredo Coordination Process

  1. Prescription routing: Oncologist sends prescription to Accredo
  2. Insurance verification: Accredo confirms PA approval
  3. Delivery coordination: Medication shipped to infusion center
  4. Administration: At approved healthcare facility

Alternative Pharmacy Options

While Accredo is preferred, you may request dispensing through:

  • Hospital outpatient pharmacy
  • Retail pharmacy (requires additional justification)
  • Home infusion provider

Important: Alternative pharmacy use requires explicit medical necessity documentation and may face additional scrutiny.

Scripts and Conversation Templates

Patient Script for Calling Cigna

"Hi, I'm calling about prior authorization for Keytruda for my cancer treatment. My member ID is [ID number]. Can you tell me the status of the PA request submitted by Dr. [Name]? If it was denied, I'd like to understand the specific reasons and start the appeal process."

Clinic Staff Script for Peer-to-Peer Review

"We're requesting a peer-to-peer review for [Patient Name]'s Keytruda prior authorization. This is for [specific cancer type] with [biomarker status]. The patient has failed [list prior therapies] and meets NCCN guidelines for pembrolizumab. Can we schedule a call with the medical director?"

When to Escalate to State Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Appeals deadlines aren't met by Cigna
  • You're denied access to external review
  • Procedural violations occur during the process

Washington OIC Consumer Advocacy:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Services: Appeal assistance, template letters, regulatory complaints

The OIC can provide template appeal letters and guide you through Washington's external review process at no cost.

FAQ

How long does Cigna prior authorization take for Keytruda in Washington? Standard PA review takes 2 business days; urgent reviews within 24 hours. Total process from submission to approval typically 3-5 business days.

What if Keytruda is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification showing formulary alternatives are ineffective or contraindicated.

Can I get expedited appeal review for cancer treatment? Yes, if treatment delay could seriously jeopardize your health, request expedited review. Cigna must respond within 72 hours for urgent appeals.

Does step therapy apply if I've already failed treatments outside Washington? Yes, document all prior therapies regardless of where treatment occurred. Cigna recognizes treatment history from any qualified healthcare provider.

How much will I pay out-of-pocket with commercial insurance? Coinsurance typically ranges 20-40% of drug cost. With Merck's copay assistance, eligible patients pay only $25 per infusion (up to $25,000 annual benefit).

What happens if external review upholds the denial? The IRO decision is final and binding. However, you can contact the Washington OIC for guidance on any procedural issues or potential regulatory complaints.

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for prescription drugs like Keytruda. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling the right clinical citations and weaving them into appeals that meet procedural requirements while tracking deadlines and required documentation.

For patients and clinicians navigating complex prior authorization and appeals processes, Counterforce Health provides time-saving templates and cleaner submissions that reduce back-and-forth with insurers, helping ensure patients get access to the medications they need.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for personalized guidance. Coverage policies and procedures may vary by plan and change over time. For the most current information, contact Cigna member services or the Washington Office of the Insurance Commissioner.

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