By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah (tisagenlecleucel) Covered by Cigna in Florida: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Kymriah (tisagenlecleucel) Covered by Cigna in Florida

Kymriah requires prior authorization through Cigna's medical benefit in Florida. Start with the Florida Medical Prior Authorization Form and submit via fax (866-873-8279) or online portal. Your clinic must document CD19-positive disease, prior therapy failures, and treatment at a certified CAR-T center. If denied, you have 180 days to file an internal appeal, followed by external review through Florida's Department of Financial Services. Call Cigna at 1-800-882-4462 to initiate the process.

Table of Contents

Start Here: Verify Your Plan and Coverage

Before starting your Kymriah (tisagenlecleucel) prior authorization, confirm these basics:

1. Check if you have Cigna commercial or Medicare coverage Call the number on your insurance card to verify your plan type. Medicare Advantage members use different forms and processes than commercial plan members.

2. Confirm Kymriah is covered under your medical benefit Most Cigna plans process CAR-T therapies like Kymriah under the medical benefit rather than pharmacy. This means your oncology team will handle the authorization, not your retail pharmacy.

3. Download Cigna's current coverage policy Cigna's Kymriah coverage policy (IP0197) outlines specific criteria for B-cell ALL (under 26 years) and relapsed/refractory DLBCL. Your treatment team should review this before submitting.

Tip: Save time by having your CAR-T center's financial navigator call Cigna first to confirm your specific plan's requirements and any pre-submission steps.

Forms You'll Need

Primary Form: Florida Medical Prior Authorization

Use Cigna's Florida Medical Prior Authorization Form (revised 09/14/2023) for all medical benefit requests in Florida.

Key sections to complete:

  • Patient demographics and Cigna member ID
  • Ordering provider (your oncologist) and rendering provider (CAR-T center)
  • Requested procedure: "CAR-T cell therapy - tisagenlecleucel (Kymriah)"
  • Section 8: Drug information including dosing and duration
  • Clinical justification with ICD-10 codes and prior therapy history

Supporting Documentation Checklist

Include these with your form:

  • Pathology report confirming CD19-positive disease
  • Complete treatment history showing prior therapy failures
  • Current staging and disease status (labs, imaging)
  • ECOG performance status documentation
  • Confirmation of treatment at FACT-accredited CAR-T center
  • Lymphodepletion chemotherapy plan (for DLBCL cases)

Submission Portals and Methods

For providers: Register for Cigna's online medical prior authorization tool by emailing [email protected] with:

  • Provider/facility name and mailing address
  • Contact person name and phone number
  • Up to 10 prescriber NPIs you want to register

Once registered, you'll receive login credentials for faster electronic submission.

Fax Submission

Fax number: 866-873-8279 Cover sheet tip: Write "URGENT - CAR-T THERAPY PA REQUEST" and include patient name and Cigna ID

Phone Follow-up

Call 1-800-882-4462 after submission to:

  • Confirm receipt of your request
  • Ask about timeline for decision
  • Request assignment to oncology case management
Note: Cigna typically acknowledges receipt within 24-48 hours and provides initial decisions within 5-7 business days for non-urgent requests.

Specialty Pharmacy Enrollment

If your Kymriah requires specialty pharmacy coordination through Express Scripts/Accredo:

Provider Portal: Register at MyAccredoPatients.com to:

  • Submit patient referrals electronically
  • Track shipment status
  • Access prior authorization tools

Patient Enrollment: Patients can track orders through the myCigna app or by calling Accredo at 877-826-7657.

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements for specialty drugs like Kymriah. Our platform can identify denial reasons and draft targeted appeals using the specific language and evidence that payers expect, potentially saving weeks in the approval process.

Support Phone Numbers

Contact Type Phone Number When to Use
Provider Services 1-800-882-4462 Prior auth requests, case management
Member Services 1-800-244-6224 Coverage verification, benefits questions
Medicare (if applicable) 1-800-668-3813 Florida Medicare Advantage plans
Accredo Specialty Pharmacy 844-516-3319 Specialty drug coordination

What to have ready when calling:

  • Patient's Cigna member ID and group number
  • Provider NPI and tax ID
  • Specific Kymriah indication (ALL vs. DLBCL)
  • Proposed treatment dates and facility

Appeals Process in Florida

Internal Appeals (Required First Step)

Deadline: 180 days from denial notice How to submit:

  • Written appeal letter addressing specific denial reasons
  • Include additional medical evidence
  • Submit via secure portal or certified mail

Timeline: Cigna must respond within 30 days for prospective requests, 60 days for retrospective claims.

External Review (After Internal Appeals)

When available: Medical necessity denials for ACA-compliant plans Deadline: 4 months after final internal denial Process: Independent medical review by qualified specialists

How to request: Follow instructions in Cigna's final denial letter, which must explain your external review rights.

Florida Department of Financial Services Support

If you need help navigating the appeals process:

Consumer Helpline: 1-877-693-5236 Online assistance: Submit a Request for Insurance Assistance

Florida's Department of Financial Services can help you understand your rights and facilitate communication with Cigna, though they cannot overturn medical necessity decisions directly.

Common Denial Reasons and Solutions

Denial Reason How to Address Required Evidence
"Not medically necessary" Submit peer-reviewed studies, NCCN guidelines Clinical literature supporting CAR-T for your specific indication
"Experimental/investigational" Reference FDA approval and Cigna's own policy FDA label, Cigna policy IP0197
"Not at approved facility" Confirm FACT accreditation FACT certification letter from treatment center
"Insufficient prior therapy" Document all previous treatments Complete treatment timeline with dates and outcomes
"Missing CD19 status" Provide flow cytometry results Pathology report confirming CD19-positive disease
From our advocates: We've seen cases where initial denials were overturned simply by resubmitting with more detailed prior therapy documentation. Cigna's reviewers need to see clear evidence that standard treatments have failed before approving CAR-T therapy. Don't assume they have your complete medical history.

When to Contact Florida Regulators

Contact the Florida Department of Financial Services if:

  • Cigna fails to respond within required timeframes
  • You're denied external review when you believe you qualify
  • The insurer isn't following proper appeal procedures

What to include in your complaint:

  • Copy of denial letters
  • Evidence of missed deadlines
  • Documentation of appeal attempts
  • Your insurance card and policy information

For urgent situations where delays could harm your health, request expedited review through both Cigna and the state regulator simultaneously.

Visit www.counterforcehealth.org to learn how our platform can help turn insurance denials into successful appeals by automatically generating evidence-backed rebuttals aligned to your specific payer's policies.

FAQ

How long does Cigna prior authorization take for Kymriah in Florida? Standard requests receive decisions within 5-7 business days. Urgent cases can be expedited to 72 hours with proper clinical justification.

What if Kymriah isn't on Cigna's formulary? CAR-T therapies are typically covered under the medical benefit regardless of formulary status. Your oncologist should submit a medical prior authorization rather than a pharmacy PA.

Can I get an expedited appeal if my condition is worsening? Yes. Document disease progression and request expedited internal and external review simultaneously. Include physician letters explaining the urgency.

Does step therapy apply to Kymriah? Cigna's policy requires documented failure of at least 2 prior systemic therapies for DLBCL cases. This isn't traditional step therapy but rather evidence of relapsed/refractory disease.

What if I received treatment in another state before moving to Florida? Include all prior therapy records regardless of location. Cigna evaluates your complete treatment history, not just Florida-based care.

Who can help if I can't afford Kymriah even with insurance? Contact Novartis patient assistance programs and check with organizations like CancerCare for additional financial support options.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare team and insurance representative for guidance specific to your situation. For regulatory assistance in Florida, contact the Department of Financial Services at 1-877-693-5236.

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