By Counterforce Health Team in Mycapssa (octreotide, oral) —

How to Get Mycapssa (Octreotide) Covered by Cigna in Virginia: Prior Authorization, Appeals, and Step-by-Step Guide

Answer Box: Getting Mycapssa Covered by Cigna in Virginia

Eligibility: Cigna covers Mycapssa for acromegaly patients who've responded to injectable octreotide or lanreotide. Fastest path: Submit prior authorization with documented response to injectable SSAs, prescriber attestation, and ICD-10 code E22.0. First step today: Contact your specialty pharmacy (typically Accredo) to initiate PA and gather your injection response documentation. If denied, Virginia's Bureau of Insurance provides external review within 120 days using Form 216-A.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission
  9. Appeals Process in Virginia
  10. Common Denial Prevention Tips

Who Should Use This Guide

This guide is for Virginia residents with Cigna coverage seeking approval for Mycapssa (octreotide) delayed-release oral capsules for acromegaly maintenance treatment. You should use this if:

  • You've been stabilized on injectable octreotide (Sandostatin LAR) or lanreotide (Somatuline Depot)
  • Your endocrinologist recommends switching to oral therapy
  • You've received a Cigna denial for Mycapssa
  • You're preparing an initial prior authorization request

Expected outcome: With proper documentation, approval rates for medically appropriate cases are significantly higher than the ~21% overall denial rate for specialty medications.

Member & Plan Basics

Coverage Verification

  • Active Coverage: Confirm your Cigna plan is active and includes specialty pharmacy benefits
  • Plan Type: Most Cigna plans route specialty drugs through Express Scripts/Accredo
  • Deductible: Verify if your specialty drug deductible has been met (typically $0-$500 for oral specialty medications)
  • Authorization Requirements: Mycapssa requires prior authorization for all Cigna plans

Cost Considerations

Mycapssa typically costs around $6,685 for a 28-day supply (56 capsules of 20mg) without insurance. With Cigna coverage, your out-of-pocket cost depends on your plan's specialty tier copay or coinsurance.

Clinical Criteria for Approval

Based on Cigna's coverage policy, Mycapssa approval requires:

Primary Requirements

  • Indication: Acromegaly diagnosis (ICD-10: E22.0)
  • Prior Response: Documented biochemical response to injectable octreotide or lanreotide
  • Specialist Prescriber: Must be prescribed by or in consultation with an endocrinologist
  • Step Therapy: Evidence of previous treatment with injectable somatostatin analogs

Clinical Documentation Needed

  • IGF-1 levels showing response to injectable therapy
  • Growth hormone suppression data
  • Treatment duration and dosing of prior injectable SSAs
  • Reason for switching from injection to oral therapy
  • Current symptom control status
Note: Mycapssa is not covered for any indication other than acromegaly maintenance in patients who've responded to injectable SSAs.

Coding Requirements

ICD-10 Diagnosis Code

  • E22.0: Acromegaly and pituitary gigantism (primary code required)
  • Additional codes if applicable: benign neoplasm of pituitary gland

NDC Numbers

Mycapssa is available under these NDC numbers:

  • 69880-120-28: 4 blister packs, 7 capsules per pack
  • 10122-550-28: 4 blister packs, 7 capsules per pack

Billing Notes

  • Mycapssa is billed as a pharmacy claim using NDC, not a J-code
  • No HCPCS J-code exists for oral octreotide as of 2024
  • Always use the exact 11-digit NDC from the dispensed package

Documentation Packet

Provider Note Elements

Your endocrinologist's note should include:

Patient History

  • Acromegaly diagnosis date and method
  • Initial IGF-1 and growth hormone levels
  • Pituitary imaging results

Prior Treatment Response

  • Injectable SSA used (octreotide LAR or lanreotide)
  • Treatment duration and dosing
  • Biochemical response data (IGF-1 normalization, GH suppression)
  • Clinical symptom improvement
  • Reasons for switching to oral therapy

Current Clinical Status

  • Most recent IGF-1 and growth hormone levels
  • Symptom control assessment
  • Treatment goals and monitoring plan

Medical Necessity Letter Components

Chiesi provides a template that should include:

  1. Patient demographics and insurance information
  2. Acromegaly diagnosis with ICD-10 code E22.0
  3. Documentation of prior injectable SSA response
  4. Clinical rationale for oral therapy
  5. Requested dosing (typically 40mg or 80mg daily)
  6. Prescriber contact information

Required Attachments

  • Recent lab results (IGF-1, growth hormone)
  • Prior authorization forms
  • Insurance card copy
  • Previous injectable SSA treatment records

Submission Process

Cigna Prior Authorization

  1. Portal Submission: Use Cigna's provider portal for fastest processing
  2. Form Requirements: Complete all required fields to avoid automatic rejections
  3. Timeline: Standard reviews take up to 60 days; expedited reviews available for urgent cases

Common Submission Errors

  • Incomplete prior treatment documentation
  • Missing IGF-1 response data
  • Incorrect NDC numbers
  • Unsigned medical necessity letters

Specialty Pharmacy Coordination

Accredo Partnership

Most Cigna members use Accredo Specialty Pharmacy for Mycapssa:

  • Accredo handles PA submission and follow-up
  • Provides patient education and adherence support
  • Coordinates with prescriber for clinical documentation
  • Manages refills and prior authorization renewals

Transfer Steps

  1. Prescriber sends prescription to Accredo
  2. Accredo contacts patient for insurance verification
  3. PA initiated if not already submitted
  4. Patient receives medication via overnight shipping once approved

After Submission

Tracking Your Request

  • Confirmation Numbers: Record all reference numbers from submissions
  • Status Checks: Follow up every 7-10 business days
  • Documentation: Keep copies of all submitted materials

Expected Timelines

  • Initial Review: 7-14 business days for complete submissions
  • Additional Information Requests: 3-5 business days response time required
  • Final Determination: Within 60 days of complete submission

Appeals Process in Virginia

Internal Appeals with Cigna

If initially denied, you have 180 calendar days to appeal:

Level 1 Appeal

  • Submit to: Cigna Healthcare National Appeals Unit, PO Box 188011, Chattanooga, TN 37422
  • Include: Original denial letter, additional clinical documentation, updated medical necessity letter
  • Timeline: 60-day review period

Level 2 Appeal

  • Automatic if Level 1 denied
  • Independent Review Organization reviews case
  • Same 60-day timeline

Virginia External Review

After exhausting Cigna's internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance:

Eligibility Requirements

  • Completed Cigna's internal appeal process
  • Denial based on medical necessity or experimental treatment determination
  • Request submitted within 120 days of final internal denial

Filing Process

  1. Complete Form 216-A External Review Request
  2. Submit supporting documentation
  3. Bureau assigns Independent Review Organization (IRO)
  4. Timeline: 45 days for standard review, 72 hours for expedited

Virginia Resources

  • Bureau of Insurance: 1-877-310-6560
  • Managed Care Ombudsman: Available through same number for HMO issues
  • No Cost: Virginia doesn't charge for external review
From Our Advocates: "We've seen Virginia patients successfully overturn Cigna denials for Mycapssa when they included comprehensive documentation of injectable SSA response and clear clinical rationale for switching to oral therapy. The key is demonstrating medical necessity beyond just patient preference."

Common Denial Prevention Tips

Five Pitfalls to Avoid

1. Insufficient Prior Treatment Documentation

  • Problem: Vague references to "previous treatment"
  • Solution: Include specific dates, dosing, duration, and quantified response data

2. Missing Biochemical Evidence

  • Problem: Clinical notes without lab values
  • Solution: Include actual IGF-1 levels before/during injectable treatment

3. Off-Label Use Requests

  • Problem: Requesting Mycapssa for non-acromegaly indications
  • Solution: Stick to FDA-approved indication with proper ICD-10 coding

4. Incomplete Specialist Documentation

  • Problem: Primary care provider prescriptions without endocrinology consultation
  • Solution: Ensure endocrinologist involvement in prescription and documentation

5. Timing Issues

  • Problem: Missing appeal deadlines or submission windows
  • Solution: Track all deadlines and submit appeals within required timeframes

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Cigna provider portal Cigna PA Policy
Step Therapy Must try injectable SSAs first Clinical documentation Same policy
Specialist Requirement Endocrinologist prescription Provider credentials Same policy
ICD-10 Code E22.0 (Acromegaly) Diagnosis documentation ICD-10 Database
Appeal Deadline 180 days from denial Cigna appeals process Cigna Appeals
External Review 120 days after internal appeals Virginia Bureau of Insurance VA External Review

FAQ

How long does Cigna prior authorization take for Mycapssa in Virginia? Standard reviews take up to 60 days, but complete submissions with proper documentation often receive decisions within 7-14 business days.

What if Mycapssa is non-formulary on my Cigna plan? You can request a formulary exception with medical necessity documentation. The process is the same as prior authorization but may require additional clinical justification.

Can I request an expedited appeal if my treatment is urgent? Yes, if your physician certifies that waiting could jeopardize your health, you can request expedited review (72 hours for Virginia external review).

Does step therapy apply if I was treated with injectables outside Virginia? Yes, prior treatment with injectable SSAs anywhere counts toward meeting step therapy requirements, as long as you have documentation.

What happens if both Cigna appeals are denied? Virginia residents can file for external review with the Bureau of Insurance, which provides an independent medical review at no cost.

How much will Mycapssa cost with Cigna coverage? Costs vary by plan, but specialty medications typically have copays of $50-$150 or coinsurance of 20-40% after deductible.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. Our platform analyzes denial letters and plan policies to identify specific coverage criteria, then drafts point-by-point rebuttals using the right clinical evidence and procedural requirements. For complex cases like Mycapssa approvals, having the right documentation and appeal strategy can make the difference between coverage and continued denials. Visit www.counterforcehealth.org to learn more about our coverage advocacy services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For assistance with insurance appeals in Virginia, contact the State Corporation Commission Bureau of Insurance or consult with qualified legal counsel.

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