By Counterforce Health Team in Kymriah (tisagenlecleucel) —

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

Answer Box: Getting Kymriah Covered by Cigna in Virginia

Cigna requires prior authorization for Kymriah (tisagenlecleucel) via their Gene Therapy Program form. Submit through CoverMyMeds or call 855-678-0051. Standard review takes 15-30 business days; expedited takes 72 hours. If denied, Virginia offers internal appeals (180 days) then external review through the State Corporation Commission (120 days). First step: Verify your plan covers specialty drugs and gather CD19 testing, prior therapy records, and oncologist documentation.

Table of Contents

  1. Verify Your Coverage
  2. Required Forms and Documentation
  3. Submission Methods
  4. Common Denial Reasons and Solutions
  5. Appeals Process in Virginia
  6. Costs and Patient Support
  7. Virginia Consumer Resources
  8. FAQ

Verify Your Coverage

Before starting the prior authorization process, confirm your Cigna plan includes specialty drug coverage. Kymriah is typically managed through Express Scripts/Accredo specialty pharmacy and requires treatment at a certified CAR-T center.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required via Gene Therapy Program Cigna Provider Portal
Formulary Status Specialty tier (verify with plan) Contact Cigna member services
Site of Care Certified CAR-T treatment center only Cigna CAR-T Policy
Age Limits ≤25 years for ALL; adults for DLBCL FDA labeling requirements
CD19 Testing Must be CD19-positive Medical necessity requirement

Required Forms and Documentation

Primary Form

Gene Therapy Program Prior Authorization Form - Download from the Cigna provider portal or access via CoverMyMeds. This specialized form replaced general oncology PA forms for CAR-T therapies.

Essential Documentation Checklist

Clinical Requirements:

  • CD19 expression testing results
  • Current disease status with imaging/labs (within 90 days)
  • Prior therapy history with dates, doses, and outcomes
  • Documentation of treatment failures or intolerance
  • Minimal residual disease (MRD) monitoring if applicable

Administrative Items:

  • Complete patient demographics and Cigna ID
  • Treating oncologist's medical necessity letter
  • Confirmation of certified CAR-T treatment center
  • 15-year follow-up compliance plan
Clinician Corner: Your medical necessity letter should detail the patient's current disease status, response to prior therapies, CD19 positivity confirmation, and why Kymriah is appropriate. Include references to FDA labeling and relevant oncology guidelines.

Submission Methods

Electronic Submission (Preferred)

  1. CoverMyMeds: www.covermymeds.com - fastest processing
  2. SureScripts: Through your EHR system
  3. Cigna Provider Portal: cignaforhcp.cigna.com

Alternative Methods

  • Fax: 833-910-1625
  • Phone: 855-678-0051 (standard) or 800-882-4462 (urgent)
  • Mail: Use portal-provided address

Timeline Expectations

  • Standard Review: 15-30 business days
  • Expedited Review: 72 hours (requires urgency documentation)
  • Follow-up: Contact after 2 weeks if no response

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing CD19 testing Submit flow cytometry or immunohistochemistry results Lab report showing CD19+ status
Not at certified center Transfer care or get center certification Facility CAR-T accreditation
Insufficient prior therapy Document treatment history with outcomes Pharmacy records, clinic notes, imaging
Medical necessity unclear Strengthen clinical rationale Updated physician letter with guidelines

Most Common Issue: Incomplete prior therapy documentation. Cigna requires evidence of specific treatment failures before approving CAR-T therapy.

Appeals Process in Virginia

If your initial request is denied, Virginia provides a structured appeals pathway with strong consumer protections.

Step-by-Step Appeals Guide

1. Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for pre-service, 60 days for post-service
  • How to file: Use denial letter instructions or call Cigna member services

2. Second-Level Internal Review

  • Automatic: If first appeal denied
  • Timeline: Additional 30-60 days
  • Peer Review: Request physician-to-physician review

3. Virginia External Review

Virginia External Review Process

The Virginia State Corporation Commission Bureau of Insurance oversees external reviews through independent medical experts. This process is particularly valuable for rare disease denials.

Contact Information:

Expedited External Review: Available if delay could seriously jeopardize health. Use Form 216-C for physician certification.

From our advocates: We've seen patients successfully overturn Kymriah denials in Virginia by submitting comprehensive prior therapy documentation and leveraging the state's expedited external review process for urgent cancer cases. The key is thorough preparation and using Virginia's consumer-friendly appeal rights.

Costs and Patient Support

Manufacturer Support

Novartis Oncology Patient Support: Contact for potential copay assistance and case management support. Eligibility varies by insurance type.

Foundation Resources

  • Leukemia & Lymphoma Society: Financial assistance programs
  • CancerCare: Copay assistance for qualifying patients
  • Patient Advocate Foundation: Insurance appeals support

Virginia-Specific Programs

Virginia's expanded Medicaid program (since 2019) has improved access to specialty drugs. If you're between jobs or income-eligible, explore Virginia Medicaid options.

Virginia Consumer Resources

State Insurance Support

Office of the Managed Care Ombudsman

  • Phone: 1-877-310-6560 or 1-804-371-9032
  • Service: Helps resolve health plan disputes and appeals

Virginia Insurance Counseling (VICAP)

  • Phone: 1-800-552-3402
  • Service: Free insurance guidance for all ages

When to Contact Regulators

File a complaint with Virginia's Bureau of Insurance if you experience:

  • Unreasonable delays in prior authorization
  • Denial without clear medical rationale
  • Failure to follow Virginia appeals procedures

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and clinicians navigate complex prior authorization requirements by identifying denial reasons and drafting point-by-point rebuttals aligned to payer policies. Learn more about our appeal support services.

FAQ

Q: How long does Cigna take to approve Kymriah in Virginia? A: Standard prior authorization takes 15-30 business days. Expedited requests (with urgency documentation) are processed within 72 hours.

Q: What if Kymriah isn't on my Cigna formulary? A: Request a formulary exception through the same Gene Therapy Program form. Include medical necessity documentation showing why covered alternatives aren't appropriate.

Q: Can I get expedited approval for urgent cases? A: Yes. Your oncologist must document that delays could jeopardize your health. Call 800-882-4462 for urgent requests.

Q: What's Virginia's external review success rate? A: Virginia doesn't publish specific overturn rates, but external reviews provide independent medical expert evaluation, particularly valuable for complex cancer treatments.

Q: Does step therapy apply to Kymriah? A: CAR-T therapies typically require documentation of prior treatment failures rather than formal step therapy. Your specific plan details may vary.

Q: How much does Kymriah cost without insurance? A: List prices are approximately $475,000 for ALL and $373,000 for DLBCL, excluding facility and administration costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance requirements change frequently - verify current policies with your plan. For personalized guidance on appeals and prior authorizations, consider consulting with Counterforce Health or other qualified patient advocacy services.

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