By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (Nivolumab) Covered by Cigna in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Opdivo Covered by Cigna in Washington

Cigna requires prior authorization for Opdivo (nivolumab) with specific medical necessity criteria. Your fastest path: Have your oncologist submit a complete PA request through CoverMyMeds or Cigna's provider portal including diagnosis, staging, biomarker results, and prior treatment history. If denied, you have 180 days to appeal internally, followed by Washington's Independent Review Organization (IRO) process. Start today: Call Cigna at 1-800-882-4462 to confirm your plan's PA requirements and formulary status.

Table of Contents

  1. Understanding Cigna's Opdivo Coverage Requirements
  2. Reading Your Denial Letter
  3. Common Fixable Issues
  4. First-Level Appeal Strategy
  5. Peer-to-Peer Review Process
  6. Washington State External Review
  7. Appeal Letter Templates
  8. Tracking and Documentation
  9. Cost-Saving Options
  10. When to Escalate

Understanding Cigna's Opdivo Coverage Requirements

Cigna requires prior authorization for Opdivo (nivolumab) across all FDA-approved indications. The drug is typically placed on a specialty tier (4 or 5) and must be filled through Accredo, Cigna's specialty pharmacy.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Provider portal or CoverMyMeds Cigna PA List
Specialty Pharmacy Must use Accredo Member portal drug search Cigna Formulary
Biomarker Testing Required for some indications FDA label and NCCN guidelines Opdivo Prescribing Info
Oncologist Required Must be prescribed by specialist PA submission requirements Cigna Oncology Policy

Medical Necessity Criteria

Cigna approves Opdivo when patients meet these requirements:

  • FDA-approved cancer diagnosis with appropriate staging documentation
  • Confirmed pathology identifying the cancer type and stage
  • Prior therapy history documented when step therapy applies
  • Prescriber specialty verification (oncologist or appropriate specialist)
  • Biomarker testing results when required (PD-L1 for some lung cancers, MSI-H/dMMR for colorectal cancer)
Note: For microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) colorectal cancer, biomarker testing confirming MSI-H or dMMR status is mandatory before approval.

Reading Your Denial Letter

When Cigna denies your Opdivo request, the denial letter contains crucial information for your appeal strategy. Look for these key elements:

Essential Information to Extract:

  • Denial date and reference number (needed for all appeals)
  • Specific denial reason (medical necessity, step therapy, non-formulary, etc.)
  • Appeal deadline (typically 180 days for commercial plans)
  • Required documentation for reconsideration
  • Contact information for appeals submission

Common Denial Codes:

  • "Does not meet coverage policy" - Missing clinical documentation
  • "Step therapy required" - Must try other treatments first
  • "Investigational/experimental" - Off-label use concerns
  • "Non-formulary" - Drug not on preferred list

Common Fixable Issues

Many Opdivo denials can be overturned by addressing documentation gaps:

Missing Biomarker Testing

Problem: Cigna requires specific biomarker results for certain indications Fix: Request your oncologist order and submit:

  • PD-L1 testing results for lung cancer patients
  • MSI/MMR testing for colorectal cancer patients
  • Molecular profiling excluding targetable mutations

Inadequate Prior Treatment Documentation

Problem: Step therapy requirements not clearly documented Fix: Provide detailed records showing:

  • Previous treatment regimens with dates
  • Objective response assessments
  • Reasons for discontinuation (progression, toxicity, intolerance)

Incomplete Staging Information

Problem: Cancer stage not adequately documented Fix: Submit complete staging workup including:

  • Pathology reports with histologic confirmation
  • Imaging studies (CT, PET, MRI as appropriate)
  • Performance status assessment

First-Level Appeal Strategy

Your first-level appeal is your strongest opportunity to overturn the denial. Washington residents have 180 days from the denial date to submit their appeal to Cigna.

Step-by-Step Appeal Process

  1. Gather Documentation (Patient/Clinic)
    • Original denial letter
    • Complete medical records
    • Pathology and imaging reports
    • Prior treatment summaries
  2. Draft Medical Necessity Letter (Oncologist)
    • Reference specific Cigna policy criteria
    • Address each denial reason point-by-point
    • Include supporting clinical evidence
  3. Submit Appeal (Clinic)
    • Use Cigna's provider portal or fax
    • Include all supporting documentation
    • Request expedited review if clinically urgent
  4. Follow Up (Patient/Clinic)
    • Confirm receipt within 3-5 business days
    • Track review timeline (typically 30 days)
    • Prepare for potential peer-to-peer review

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Patient demographics and Cigna member information
  • Specific cancer diagnosis with ICD-10 codes
  • Disease staging and progression status
  • Prior treatment history with outcomes
  • Clinical rationale for Opdivo selection
  • References to FDA prescribing information or NCCN guidelines
  • Planned dosing schedule and monitoring plan

Peer-to-Peer Review Process

If your written appeal doesn't succeed, request a peer-to-peer review with Cigna's medical director. This conversation can be pivotal in overturning denials.

Preparation Checklist

  • Review Cigna's specific denial rationale
  • Prepare 2-minute case summary aligned with policy criteria
  • Gather supporting evidence (guidelines, trial data, FDA approval)
  • Anticipate common objections (alternatives, step therapy, cost)

Call Strategy

  1. Open with clear case summary - diagnosis, stage, prior treatments
  2. Address policy criteria systematically - walk through each requirement
  3. Handle "investigational" concerns - emphasize FDA approval and guidelines
  4. Document the conversation - names, dates, key points discussed
  5. Request written confirmation of any verbal approvals
From Our Advocates: In our experience helping patients navigate Cigna appeals, peer-to-peer calls are most successful when the oncologist can demonstrate that the patient has exhausted standard alternatives and that Opdivo represents the most appropriate next step based on established guidelines. Having specific biomarker results and prior treatment response data readily available significantly strengthens the case.

Washington State External Review

If Cigna upholds their denial after internal appeals, Washington residents can request an Independent Review Organization (IRO) evaluation through the Washington State Office of the Insurance Commissioner.

External Review Process

  • Timeline: Must request within 60 days of final internal denial
  • Decision timeframe: IRO decides within 20 days (72 hours for expedited)
  • Cost: No charge to the patient
  • Binding: Decision is final and binding on Cigna

How to Request External Review

  1. Contact your insurer to request external review forms
  2. Submit request with denial letters and medical records
  3. Provide additional information within 5 business days if requested
  4. Await IRO decision - independent medical experts review your case

Contact Information:

Appeal Letter Templates

Basic Appeal Structure

[Date]

Cigna Healthcare
National Appeals Unit
[Address from denial letter]

Re: Appeal for [Patient Name]
Member ID: [Number]
Denial Date: [Date]
Reference Number: [From denial letter]

Dear Appeals Review Team,

I am writing to formally appeal the denial of Opdivo (nivolumab) for [patient name], who has been diagnosed with [specific cancer type and stage]. This denial was issued on [date] with reference number [number].

PATIENT INFORMATION:
- Diagnosis: [Cancer type with ICD-10 code]
- Stage: [Clinical/pathologic staging]
- Prior treatments: [List with dates and outcomes]
- Current status: [Performance status, disease progression]

DENIAL RATIONALE AND RESPONSE:
The denial stated "[quote exact denial reason]." However, this patient meets all criteria in Cigna's Oncology Coverage Policy because:
[Address each criterion point by point]

MEDICAL NECESSITY:
[Clinical rationale with supporting evidence]

REQUESTED ACTION:
Please overturn this denial and approve Opdivo (nivolumab) [dose and schedule] for [duration] based on the medical necessity demonstrated above.

Sincerely,
[Oncologist name and credentials]

Tracking and Documentation

Maintaining detailed records strengthens your appeal and helps identify patterns if multiple denials occur.

Documentation Log Template

  • Date of each communication
  • Person contacted (name and title)
  • Method of contact (phone, fax, portal)
  • Reference numbers for all submissions
  • Outcome and next steps
  • Deadlines for responses or actions

Key Deadlines for Washington Residents:

  • Internal appeal: 180 days from denial
  • External review request: 60 days from final internal denial
  • Additional information to IRO: 5 business days when requested

Cost-Saving Options

Even with insurance approval, Opdivo's specialty tier placement can result in significant out-of-pocket costs.

Financial Assistance Programs

  • Bristol Myers Squibb Patient Assistance - Copay cards and foundation grants
  • Cancer financial assistance foundations - Additional support for eligible patients
  • State pharmaceutical assistance programs - Washington-specific resources

Pharmacy Options

  • Accredo specialty pharmacy (required by most Cigna plans)
  • In-clinic administration may have different cost-sharing
  • 340B program savings at eligible healthcare facilities

When to Escalate

If internal appeals and external review don't resolve your case, additional options remain available in Washington.

State Regulator Complaints

Contact the Washington Office of the Insurance Commissioner if you believe Cigna:

  • Failed to follow proper appeal procedures
  • Made decisions not supported by medical evidence
  • Violated state insurance regulations

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned with each plan's own rules. For complex cases involving specialty oncology drugs like Opdivo, their expertise in payer-specific workflows and evidence compilation can significantly improve appeal success rates.

Frequently Asked Questions

How long does Cigna prior authorization take in Washington? Standard review takes up to 15 business days. Expedited review is available within 72 hours for urgent medical situations.

What if Opdivo is non-formulary on my plan? Request a formulary exception through your oncologist. Provide clinical rationale for why preferred alternatives are inappropriate.

Can I request an expedited appeal? Yes, if treatment delay could seriously jeopardize your health. Your oncologist must document the clinical urgency.

Does step therapy apply if I've tried treatments outside Washington? Yes, prior treatments from any location count toward step therapy requirements if properly documented.

What happens if the IRO denies my external review? The IRO decision is final for insurance purposes, but you can still file complaints with state regulators or seek legal counsel.

Are there alternatives if Opdivo remains denied? Other PD-1/PD-L1 inhibitors (Keytruda, Libtayo) may be covered, or your oncologist can explore targeted therapies based on your tumor's molecular profile.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional support with insurance appeals, consider consulting with Counterforce Health, which specializes in evidence-based appeal strategies for specialty medications.

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