By Counterforce Health Team in Orkambi (lumacaftor/ivacaftor) —

How to Get Orkambi (lumacaftor/ivacaftor) Covered by Cigna in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Get Orkambi Covered by Cigna in Pennsylvania

Cigna requires prior authorization (PA) for Orkambi (lumacaftor/ivacaftor) coverage in Pennsylvania. Your fastest path to approval: (1) Download Cigna's Orkambi PA form, (2) Have your CF specialist complete it with genetic testing confirming F508del homozygous mutation, and (3) Fax to 855-840-1678. Standard approval takes 5 business days; urgent cases get 24-hour review. If denied, Pennsylvania's new external review program overturns about 50% of appeals. Start today by calling the number on your Cigna ID card to confirm PA requirements.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Complete Cigna's Orkambi Prior Authorization
  3. Submit Through Cigna's Portals and Fax Lines
  4. Work with Accredo Specialty Pharmacy
  5. Appeal Process: Internal and External Reviews
  6. Pennsylvania External Review Program
  7. Contact Numbers and Support Resources
  8. Cost Assistance and Patient Programs

Verify Your Plan and Find the Right Forms

Before starting your Orkambi prior authorization, confirm your specific Cigna plan requirements. Most Cigna plans in Pennsylvania manage specialty drugs through Express Scripts or Accredo, which means you'll need to use Cigna's specialty drug PA process.

Coverage at a Glance

Requirement Details Where to Find It
PA Required? Yes, for all Cigna plans Cigna formulary
Formulary Tier Typically Tier 5 (specialty) Your plan documents or myCigna.com
Age Requirements FDA-approved ages per label Orkambi PA form
Genetic Testing F508del homozygous required Cigna coverage policy
Specialist Required CF specialist or consultant Coverage criteria
Appeals Deadline 180 days from denial Cigna member guide

First step: Log into myCigna.com or call the customer service number on your ID card to verify your plan includes Orkambi coverage and confirm whether you need to use Accredo specialty pharmacy.

Complete Cigna's Orkambi Prior Authorization

Cigna uses a specific PA form for Orkambi that your CF specialist must complete. Download the current version from Cigna's prescription forms library.

Required Information for Your Doctor

Patient Details:

  • Full name, Cigna ID number, date of birth
  • Current address and phone number
  • Weight (if patient is age 2-5 years)

Clinical Documentation:

  • Diagnosis: Cystic fibrosis with ICD-10 code
  • Genetic confirmation: Lab results showing F508del homozygous mutation
  • Prescriber credentials: DEA, NPI, and TIN numbers
  • Treatment history: Previous CFTR modulators tried (if any)
Clinician Corner: Medical Necessity Letter Checklist

Your CF specialist should include:Confirmed F508del homozygous genotype with lab reportCurrent lung function (FEV1) and symptomsPrior therapies attempted and outcomesClinical rationale citing FDA labelingDosing plan based on patient age and weight

Common Denial Reasons & How to Prevent Them

Denial Reason Prevention Strategy
Missing genetic testing Include complete CFTR gene analysis showing F508del/F508del
Non-specialist prescriber Ensure prescription comes from pulmonologist or CF center
Incomplete age documentation Verify patient meets FDA age requirements in application
Quantity limit exceeded Justify higher doses with clinical history if needed

Submit Through Cigna's Portals and Fax Lines

Once your PA form is complete, submit it through Cigna's preferred channels for fastest processing.

Submission Options

Primary Fax Line: 855-840-1678

  • Include completed PA form and all supporting documents
  • Add cover sheet with patient name and Cigna ID
  • Allow 24-48 hours for acknowledgment

Online Portals:

  • CoverMyMeds: Preferred electronic submission
  • SureScripts: EHR integration available
  • Cigna for Healthcare Professionals: Provider portal access

Phone for Urgent Cases: 800-882-4462

  • Use for expedited reviews when health is at risk
  • Have PA form and patient information ready
  • Document your call with reference number

Timeline Expectations

  • Standard Review: 5 business days
  • Urgent/Expedited: 24 hours (requires clinical justification)
  • Auto-approval: May occur if no response within 72 hours (check your specific plan)

Work with Accredo Specialty Pharmacy

Most Cigna plans require Orkambi to be filled through Accredo, Cigna's specialty pharmacy partner.

Enrollment Process

  1. After PA approval, Accredo will contact you within 24-48 hours
  2. Verify shipping address and preferred delivery times
  3. Set up automatic refills and copay assistance enrollment
  4. Coordinate with your doctor for prescription transfer

Accredo Contact: 877-826-7657

  • Hours: Monday-Friday 7am-10pm CST, Saturday 7am-4pm CST
  • Have your Cigna ID and PA approval number ready
From Our Advocates

Many families find success by staying proactive during the Accredo enrollment process. One tip we often share: call Accredo directly after receiving PA approval rather than waiting for them to contact you. This can speed up the initial fill by several days, which matters when you're eager to start treatment.

Appeal Process: Internal and External Reviews

If your initial PA request is denied, don't give up. Cigna has a structured appeals process, and Pennsylvania offers additional external review options.

Step-by-Step Appeals Process

Level 1 Internal Appeal (Required First Step)

  1. Submit within 180 days of denial notice
  2. Use Cigna's appeal form or write a letter including:
    • Copy of denial letter
    • Updated medical necessity letter from CF specialist
    • Additional clinical evidence (recent labs, lung function tests)
    • Peer-reviewed studies supporting Orkambi use

Submission Options:

  • Mail: Cigna Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Fax: Number provided in your denial letter
  • Online: myCigna.com appeals portal

Timeline: 30 days for medical necessity decisions; 60 days for administrative issues

Level 2 Internal Appeal

  • Submit within 60 days of Level 1 denial
  • Include any new clinical information
  • Same submission process as Level 1

When to Request Expedited Appeals

Expedited review (72 hours) applies when:

  • Delay could seriously jeopardize your health
  • Waiting could significantly reduce effectiveness of treatment
  • You're experiencing rapid decline in lung function

Call 1-800-88-CIGNA to request expedited review and explain the urgency.

Pennsylvania External Review Program

Pennsylvania launched its Independent External Review Program in January 2024, giving residents a powerful new tool to fight insurance denials.

Key Benefits for Pennsylvania Residents

  • 50% success rate in first year of operation
  • Independent medical review by qualified physicians
  • Free to patients - no filing fees
  • Binding decisions - Cigna must comply with favorable rulings

How to Access External Review

Eligibility Requirements:

  • Must complete Cigna's internal appeals process first
  • Have a "Final Adverse Benefit Determination" letter
  • Not enrolled in a self-funded employer plan (check with HR)

Submission Process:

  1. File within 4 months of final internal denial
  2. Use Pennsylvania's online portal at pa.gov external review
  3. Upload supporting documents:
    • Final denial letter from Cigna
    • All internal appeal correspondence
    • Updated medical records and specialist letters
    • Research supporting Orkambi's medical necessity

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (for urgent health situations)

What Happens if You Win

If the independent review organization overturns Cigna's denial:

  • Immediate coverage begins
  • Retroactive reimbursement for out-of-pocket costs during appeal
  • No further appeals by Cigna allowed

Pennsylvania Insurance Department Consumer Services: 1-877-881-6388

Contact Numbers and Support Resources

Keep these key contacts handy throughout your approval process:

Cigna Contacts

Service Phone Number Best Used For
Customer Service Number on your ID card General questions, PA status
Prior Authorization 800-882-4462 Urgent PA requests, status updates
Appeals Hotline 800-244-6224 Filing appeals, deadline questions
Provider Services 800-88-CIGNA For your doctor's office

Pennsylvania Resources

  • PA Insurance Department: 1-877-881-6388
  • PA Health Law Project: Free consumer assistance
  • External Review Portal: pa.gov insurance services

Specialty Support

  • Accredo Specialty Pharmacy: 877-826-7657
  • Cystic Fibrosis Foundation: cff.org - Free PA assistance
  • Vertex Patient Services: Support for Orkambi patients

Counterforce Health specializes in turning insurance denials into successful appeals by crafting evidence-backed rebuttals that align with each payer's specific policies. Their platform helps patients and clinicians navigate complex prior authorization requirements and build compelling cases for coverage approval. Learn more at counterforcehealth.org.

Cost Assistance and Patient Programs

Even with insurance coverage, Orkambi can be expensive. Several programs can help reduce your out-of-pocket costs:

Manufacturer Support

Vertex Patient Services:

  • Copay assistance for eligible patients
  • Free drug program for uninsured/underinsured
  • Insurance navigation support
  • Available through your CF care center

Foundation Assistance

Cystic Fibrosis Foundation:

  • Compass program for insurance appeals
  • Financial assistance for CF-related costs
  • Care center directory and resources

HealthWell Foundation:

  • Grants for specialty drug copays
  • Income-based eligibility requirements

State Programs

Pennsylvania residents may qualify for:

  • PACE/PACENET: Prescription assistance for seniors
  • Medicaid: Expanded coverage in Pennsylvania
  • CHIP: Children's health insurance program

Frequently Asked Questions

How long does Cigna's PA process take for Orkambi in Pennsylvania? Standard review takes 5 business days; urgent cases are reviewed within 24 hours. Electronic submission through CoverMyMeds typically processes faster than fax.

What if Orkambi isn't on my Cigna formulary? You can request a formulary exception using Cigna's exception form. Include medical necessity documentation and evidence that formulary alternatives aren't appropriate.

Can I get an expedited appeal if my lung function is declining? Yes. Document rapid decline with recent lung function tests and have your CF specialist call Cigna to request expedited review, emphasizing medical urgency.

Does Pennsylvania's external review cost anything? No. Pennsylvania's Independent External Review Program is free to patients and has no filing fees.

What happens if I start paying out-of-pocket during appeals? Keep all receipts. If your appeal succeeds, Cigna must reimburse your out-of-pocket costs retroactively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider and insurance plan documents for specific coverage details. Coverage policies and procedures may change; verify current requirements with Cigna and Pennsylvania regulators.

For complex cases requiring specialized appeal expertise, Counterforce Health helps transform insurance denials into targeted, evidence-backed appeals that align with payer policies and procedural requirements.

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