By Counterforce Health Team in Oxlumo (lumasiran) —

How to Get Oxlumo (Lumasiran) Covered by Cigna in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Oxlumo Covered by Cigna in Pennsylvania

Cigna requires prior authorization for Oxlumo (lumasiran) with genetic confirmation of PH1, elevated urinary oxalate levels, and prescription by a nephrologist or urologist. Submit PA through CoverMyMeds or EviCore portal with AGXT mutation results and baseline labs. If denied, use Cigna's internal appeals (180 days), then Pennsylvania's external review program (4 months) which overturns ~50% of denials. Start today: Call the number on your Cigna ID card to verify specialty pharmacy benefits and request PA forms.

Table of Contents

  1. Verify Your Cigna Plan Coverage
  2. Prior Authorization Requirements
  3. Submission Portals and Forms
  4. Appeals Process: Internal to External
  5. Specialty Pharmacy Enrollment
  6. Support Resources and Contacts
  7. Pennsylvania Consumer Protections
  8. Keeping Information Current

Verify Your Cigna Plan Coverage

Before starting your Oxlumo prior authorization, confirm your plan details and formulary status:

Check Your Coverage:

  • Log into myCigna.com or call the member services number on your ID card
  • Verify Oxlumo is managed through Express Scripts/Accredo specialty pharmacy
  • Confirm you don't have a self-funded employer plan (which may have different appeal rights)
Note: Most Cigna plans require specialty drugs like Oxlumo to go through their designated specialty pharmacy network, typically Accredo.

Coverage at a Glance:

Requirement Details Where to Find
Prior Authorization Required for all plans Cigna PA Forms
Formulary Tier Specialty (Tier 4-5) myCigna portal or formulary PDF
Prescriber Requirement Nephrologist or urologist Cigna Oxlumo Policy
Genetic Testing AGXT mutations required Same policy document
Step Therapy None typically required Plan-specific; check with Cigna

Prior Authorization Requirements

Cigna's coverage criteria for Oxlumo are specific and well-documented. Here's exactly what you need:

Core Medical Requirements

1. Confirmed PH1 Diagnosis:

  • Genetic testing showing biallelic AGXT mutations from CLIA-certified lab
  • Alternative: Liver biopsy showing AGT deficiency (if genetics unavailable)
  • ICD-10 code: E72.53 (Primary hyperoxaluria)

2. Elevated Oxalate Levels (one required):

  • 24-hour urinary oxalate ≥0.5 mmol/24 hours/1.73 m² (some policies require ≥0.7)
  • Spot urinary oxalate:creatinine ratio above age-specific normal
  • Plasma oxalate ≥20 µmol/L (especially if eGFR <30)

3. Prescriber Qualification:

  • Board-certified nephrologist or urologist
  • Must document ongoing specialist care

4. Exclusions to Confirm:

  • No prior liver transplant for PH1
  • eGFR typically ≥30 mL/min/1.73 m² documented

Clinician Corner: Medical Necessity Letter

Your nephrologist's letter should include:

✓ Patient demographics and diagnosis with ICD-10 code E72.53
✓ Genetic test results showing specific AGXT mutations
✓ Baseline oxalate levels with lab dates and reference ranges
✓ Prior conservative therapies tried (diet modification, increased fluids, pyridoxine, citrate)
✓ Clinical rationale citing FDA labeling and treatment guidelines
✓ Weight-based dosing plan per FDA recommendations
✓ Monitoring plan for urinary oxalate reduction

Submission Portals and Forms

Electronic Submission (Preferred)

Primary Options:

  1. CoverMyMeds - Search "Oxlumo" for drug-specific form
  2. EviCore by Evernorth - Select "Pharmacy Drugs (Express Scripts Coverage)"
  3. ExpressPAth - Express Scripts dedicated portal
  4. Surescripts - EHR-integrated submissions

Required Documentation Upload

  • Completed PA form
  • Medical necessity letter from nephrologist
  • AGXT genetic testing report
  • Baseline laboratory results (urinary/plasma oxalate, creatinine)
  • Patient insurance information and weight for dosing

Backup Submission Methods

If electronic portals are unavailable:

  • Fax: Use number provided in denial letter or call 1-800-882-4462 for current fax
  • Mail: Include complete documentation package with cover letter
Tip: Electronic submissions process 70% faster than fax/mail and provide real-time status updates.

Appeals Process: Internal to External

Step-by-Step Appeals Pathway

Level 1: Internal Appeal (Required First)

  • Deadline: 180 days from denial date
  • Submit to: Cigna Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Include: Original denial letter, updated medical necessity letter, new supporting evidence
  • Timeline: 30 days for medical necessity reviews

Level 2: Second Internal Appeal

  • Deadline: 60 days from Level 1 denial
  • Process: Independent reviewer within Cigna
  • Same submission methods as Level 1

External Review: Pennsylvania's Independent Program

  • Eligibility: After final internal denial; commercial plans only (not self-funded employer plans)
  • Deadline: 4 months from final adverse determination
  • Submit: pa.gov/reviewmyclaim
  • Success rate: ~50% of denials overturned in Pennsylvania's first year

Common Denial Reasons & Solutions

Denial Reason How to Address Required Documentation
"No genetic confirmation" Submit complete AGXT test results CLIA-certified lab report with specific mutations
"Oxalate levels insufficient" Provide multiple measurements 24-hour urine collections or plasma oxalate ≥20 µmol/L
"Non-specialist prescriber" Transfer care or obtain consultation Nephrologist or urologist evaluation and ongoing care plan
"Insufficient medical necessity" Enhanced clinical documentation Detailed history, failed conservative measures, treatment goals

Specialty Pharmacy Enrollment

Accredo Enrollment Process

Once PA is approved, Cigna typically directs Oxlumo prescriptions to Accredo specialty pharmacy:

Enrollment Steps:

  1. Prescription Transfer: Your nephrologist sends prescription to Accredo
  2. Patient Intake: Accredo calls within 24-48 hours for insurance verification
  3. Financial Counseling: Review copay, deductible, and assistance programs
  4. Delivery Setup: Home delivery or clinic administration coordination

Submission Methods to Accredo:

  • Electronic Medical Record (EMR) integration
  • MyAccredoPatients provider portal
  • FaxRx system
  • Phone: Contact through Cigna member services

Financial Assistance During Process

Alnylam Support Programs:

  • Alnylam Assist Bridge: Free medication during PA delays
  • Copay Program: Reduces out-of-pocket costs post-approval
  • Act PH1 Sponsored Testing: Free genetic testing for eligible patients
From Our Advocates: "We've seen patients successfully bridge coverage gaps by enrolling in manufacturer assistance programs early in the PA process. Don't wait for a denial—apply for bridge programs as soon as your nephrologist submits the PA. This composite tip represents common successful strategies, though individual outcomes vary."

Support Resources and Contacts

Cigna Contact Information

Member Services: Number on your Cigna ID card

  • PA status inquiries
  • Appeals submission guidance
  • Specialty pharmacy coordination

Provider Services: 1-800-882-4462

  • Clinical prior authorization support
  • Peer-to-peer review requests
  • Formulary exception processes

Pennsylvania-Specific Resources

Pennsylvania Insurance Department:

  • Consumer Services: 1-877-881-6388
  • External Review Portal: pa.gov/reviewmyclaim
  • Consumer Assistance: Free help with complex appeals through Pennsylvania Health Law Project

Pennie (PA Marketplace) Support:

  • If your plan was purchased through Pennie
  • Consumer hotline available on Pennie.com

Pennsylvania Consumer Protections

External Review Program Advantages

Pennsylvania's Independent External Review Program, launched January 2024, offers significant advantages:

Key Benefits:

  • State oversight instead of federal default process
  • 50% overturn rate in first year of operation
  • Binding decisions on insurers like Cigna
  • Free process with no cost to consumers

Timeline for External Review:

  • Standard: 45 days from assignment to independent review organization
  • Expedited: 72 hours for urgent, life-threatening situations
  • Information gathering: 15 business days to submit additional evidence

When to Use External Review

Consider external review for Oxlumo denials involving:

  • Disputes over "experimental" vs. FDA-approved status
  • Medical necessity determinations despite meeting published criteria
  • Specialty prescriber requirement interpretations
  • Genetic testing adequacy questions

Keeping Information Current

Regular Updates to Check

Quarterly Reviews:

  • Cigna formulary changes (typically January updates)
  • PA form revisions on CoverMyMeds
  • Pennsylvania Insurance Department policy updates

Annual Verification:

  • Plan renewal and formulary tier changes
  • Specialty pharmacy network updates
  • Appeal deadline and process modifications

Resources for Updates:

Frequently Asked Questions

How long does Cigna PA take for Oxlumo in Pennsylvania? Standard PA decisions take 5 business days; expedited reviews for urgent cases take 24-72 hours. Electronic submissions via CoverMyMeds typically process faster than fax.

What if Oxlumo is non-formulary on my plan? Request a formulary exception through the same PA process. Include medical necessity documentation and evidence that formulary alternatives are inappropriate for PH1.

Can I request an expedited appeal if my kidney function is declining? Yes. Contact Cigna member services to request expedited review for urgent medical situations. Your nephrologist should document the urgency in their clinical notes.

Does Pennsylvania's external review cover all Cigna plans? No. Self-funded employer plans are exempt from state external review. Check with your HR department or call Cigna to verify your plan type.

How much does Oxlumo cost if PA is denied? List price is approximately $493,000 annually. The Alnylam Assist Bridge Program provides free medication during appeals, and Counterforce Health can help draft targeted appeals to overturn denials.

Sources & Further Reading

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful, evidence-backed appeals. Our platform analyzes denial letters and payer policies to draft targeted rebuttals that address specific coverage criteria, increasing approval rates for complex specialty medications like Oxlumo. If you're facing a Cigna denial for Oxlumo in Pennsylvania, Counterforce Health can help you build a stronger appeal with the right clinical evidence and payer-specific arguments.

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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