How to Get Pemazyre (Pemigatinib) Approved by Cigna in Florida: Timeline, Forms, and Appeal Strategy

Answer Box: Getting Pemazyre Covered by Cigna in Florida

Cigna covers Pemazyre (pemigatinib) for cholangiocarcinoma with FGFR2 fusion/rearrangement after prior therapy, but requires prior authorization. Standard review takes 5 business days; urgent cases get 24-72 hour decisions. Required documentation: FGFR2 test results, baseline eye exam, prior therapy records, and drug interaction screening. If denied, you have 180 days to appeal internally, then external review through Florida's Department of Financial Services. First step: Have your oncologist submit the PA with complete documentation through Cigna's provider portal or fax to Express Scripts/Accredo.

Table of Contents

1. What Affects Approval Timing
2. Pre-Submission Preparation (0-2 Days)
3. Submission to Initial Review (1-5 Days)
4. Additional Information Requests (1-7 Days)
5. Decision Window and Outcomes
6. If Denied: Appeal Process
7. Renewal Cycles
8. Timeline Visual
9. Time-Saving Tips

Coverage at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Required for all Pemazyre prescriptions	Cigna provider portal	Cigna PA Policy
FGFR2 Testing	Documented fusion/rearrangement required	Lab pathology report	Cigna Coverage Criteria
Prior Therapy	At least one systemic treatment	Medical records	FDA Label Requirements
Eye Exam	Baseline OCT required	Ophthalmology report	Cigna Monitoring Requirements
Age Limit	18 years or older	Medical records	Cigna Policy
Appeal Deadline	180 days from denial	Denial letter	Florida Insurance Law

What Affects Approval Timing

Several factors influence how quickly Cigna approves Pemazyre in Florida:

Documentation Completeness: The biggest factor is having all required materials upfront. Cigna's standard review timeline is 5 business days, but incomplete submissions can add 1-7 days for additional information requests.

Clinical Urgency: For patients with rapidly progressing disease, urgent requests can be processed in 24-72 hours when medical urgency is documented.

Plan Type: Cigna processes specialty drugs through Express Scripts/Accredo, which may have slightly different timelines than standard medications. Medicare Advantage plans follow federal guidelines, while commercial plans use Florida state requirements.

Note: Under Florida law, prescription drug prior authorizations must be decided within 72 hours for non-urgent cases and 24 hours for urgent situations.

Pre-Submission Preparation (0-2 Days)

Checklist: Gather These Documents First

✓ FGFR2 Test Results: Lab report showing specific fusion or rearrangement
✓ Pathology Report: Confirming cholangiocarcinoma diagnosis
✓ Prior Treatment Records: Documentation of previous systemic therapy and outcomes
✓ Baseline Eye Exam: Comprehensive ophthalmologic exam with OCT
✓ Drug Interaction Screen: Medication reconciliation showing no contraindicated drugs
✓ Insurance Information: Policy number, member ID, and prescriber NPI

Verify Coverage Details

Contact Cigna at 1-800-244-6224 to confirm:

• Your specific plan's formulary tier for Pemazyre
• Whether step therapy requirements apply
• Current prior authorization forms needed

Submission to Initial Review (1-5 Days)

Step-by-Step: Fastest Path to Approval

1. Electronic Submission (Recommended): Your oncologist submits through Cigna's provider portal or CoverMyMeds for fastest processing.
2. Include Medical Necessity Letter: Must address all Cigna criteria:
   • Confirmed unresectable/metastatic cholangiocarcinoma
   • FGFR2 fusion/rearrangement documentation
   • Prior systemic therapy history and outcomes
   • Clinical rationale for Pemazyre specifically
3. Submit to Correct Entity: Cigna processes specialty drugs through Express Scripts/Accredo. Fax option: 866-873-8279.
4. Mark as Urgent if Applicable: Include documentation of rapid disease progression or clinical deterioration.

Clinician Corner: The medical necessity letter should reference NCCN guidelines for cholangiocarcinoma and explain why Pemazyre is the appropriate targeted therapy based on the patient's FGFR2 alteration.

Additional Information Requests (1-7 Days)

If Cigna requests additional information, respond within 24-48 hours to avoid delays:

Common Requests Include:

• More detailed prior therapy documentation
• Clarification of FGFR2 testing methodology
• Updated imaging showing disease status
• Ophthalmology consultation notes

How to Respond Quickly:

• Use secure provider portal for fastest transmission
• Include a cover letter referencing the original PA request number
• Provide complete documentation rather than partial responses

Decision Window and Outcomes

Typical Timeline: 5 business days for standard requests, 24-72 hours for urgent cases.

Reading Your Approval Letter:

• Approved: Letter will specify coverage duration (typically 12 months) and any quantity limits
• Denied: Must include specific reason and appeal instructions per Florida law
• Pending: Additional information needed; respond promptly to avoid automatic denial

If Denied: Appeal Process

Internal Appeal (Level 1)

• Deadline: 180 days from denial notice
• Timeline: Cigna has 30 days to respond (60 days for retrospective claims)
• Submit via: Cigna provider portal or appeals fax line

Internal Appeal (Level 2)

• Deadline: 60 days from Level 1 denial
• Process: Independent medical review by different Cigna physicians
• Timeline: 30-45 days for decision

External Review (Florida)

• Eligibility: After exhausting internal appeals
• Deadline: 4 months from final internal denial
• Process: Independent review through Florida Department of Financial Services
• Cost: Free to consumers
• Timeline: Standard cases within 45 days; urgent cases within 72 hours

From Our Advocates: We've seen Pemazyre appeals succeed when providers include detailed FGFR2 testing reports and emphasize the lack of alternative targeted therapies for this specific molecular subtype. Strong clinical documentation showing prior therapy failures significantly improves approval odds.

Common Denial Reasons & Fixes

Denial Reason	How to Overturn
No FGFR2 documentation	Submit complete lab report with specific fusion/rearrangement details
Insufficient prior therapy	Provide detailed records of all previous treatments and outcomes
Missing eye exam	Submit baseline ophthalmologic evaluation with OCT
Drug interactions	Include medication reconciliation showing no contraindicated drugs
Not medically necessary	Emphasize targeted nature of therapy and lack of alternatives

Renewal Cycles

When to Re-authorize: Most approvals last 12 months. Submit renewal requests 30-45 days before expiration.

What Speeds Renewals:

• Updated imaging showing treatment response
• Ophthalmology monitoring reports
• Documentation of continued FGFR2+ disease
• Absence of significant toxicities

Changes That May Affect Renewal:

• Disease progression requiring combination therapy
• New safety monitoring requirements
• Updated Cigna coverage policies

Timeline Overview

Phase	Timeline	Key Activities	Success Factors
Pre-submission	0-2 days	Gather documentation	Complete FGFR2 testing, eye exam
Initial submission	1-5 days	PA review	Electronic submission, complete records
Additional info	1-7 days	Respond to requests	Quick, complete responses
Decision	5-14 days	Approval/denial	Clear medical necessity
Internal appeal	30-60 days	Level 1 & 2 reviews	Strong clinical evidence
External review	45 days	Independent review	Comprehensive appeal packet

Time-Saving Tips

Portal Usage: Electronic submissions through Cigna's provider portal process 2-3 days faster than fax submissions.

Bundled Evidence: Submit all required documentation together rather than piecemeal to avoid back-and-forth requests.

Direct Specialty Routing: Ensure submissions go directly to Express Scripts/Accredo rather than general Cigna medical management.

Peer-to-Peer Strategy: If initially denied, request a peer-to-peer review with a Cigna oncologist who understands FGFR-targeted therapies.

Counterforce Health Support: Platforms like Counterforce Health help patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by identifying denial basis and drafting point-by-point rebuttals aligned to the plan's own rules.

FAQ

How long does Cigna prior authorization take in Florida? Standard requests: 5 business days. Urgent requests: 24-72 hours when medical urgency is documented.

What if Pemazyre is non-formulary on my plan? Request a formulary exception with comprehensive clinical justification emphasizing the targeted nature of therapy and lack of alternatives.

Can I request an expedited appeal? Yes, if you have rapidly progressing disease or urgent medical needs, both internal and external appeals can be expedited in Florida.

Does step therapy apply to Pemazyre? Cigna requires documentation of prior systemic therapy, but specific step therapy protocols vary by plan. Verify requirements with your specific policy.

What counts as medical necessity for Pemazyre? Documented FGFR2 fusion/rearrangement, unresectable/metastatic cholangiocarcinoma, prior systemic therapy, and appropriate monitoring plan.

When to Escalate

If Cigna doesn't respond within required timeframes or denials seem inappropriate, contact:

Florida Office of Insurance Regulation
Consumer Helpline: 1-877-693-5236
File complaint online

Florida Department of Financial Services
For external review requests and insurance concerns
Consumer Services Division

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Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by specific plan and change over time. Always consult your healthcare provider and insurance documents for the most current information. Counterforce Health provides tools to help navigate insurance coverage but cannot guarantee approval outcomes.

Sources & Further Reading

• Cigna Pemazyre Coverage Policy (PDF)
• Cigna Prior Authorization Process
• Express Scripts PA Timeline
• Florida Insurance Appeals Process
• Accredo Prior Authorization

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