By Counterforce Health Team in Pemazyre (pemigatinib) —

How to Get Pemazyre (Pemigatinib) Covered by Cigna in Pennsylvania: Prior Authorization Forms, Appeals, and Coding Guide

Answer Box: Getting Pemazyre Covered by Cigna in Pennsylvania

Eligibility: Adults with FGFR2-positive cholangiocarcinoma or FGFR1-positive myeloid/lymphoid neoplasms who've tried prior therapy. Fastest path: Submit Cigna's prior authorization with FGFR test results and ophthalmologic monitoring plan. First step today: Contact your oncologist to order FGFR testing if not done, then request the PA form through Cigna's provider portal. If denied, Pennsylvania's new external review program has a 50% overturn rate within 45 days.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Coding Basics: Medical vs. Pharmacy Benefit
  3. ICD-10 Diagnosis Codes and Documentation
  4. Product Coding: NDC Numbers and Billing Units
  5. Clean Prior Authorization Request
  6. Common Coding Pitfalls to Avoid
  7. Verification with Cigna Resources
  8. Appeals Process in Pennsylvania
  9. Pre-Submission Audit Checklist
  10. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Cigna Provider Portal Cigna Policy
FGFR Testing FGFR2 fusion/rearrangement confirmed FDA-approved companion diagnostic FDA Label
Age Requirement 18+ years Cigna coverage policy Cigna Policy
Prior Therapy At least one systemic regimen Document dates and outcomes Cigna Policy
Eye Monitoring Plan Required due to RPED risk Every 2 months initially FDA Label
Coverage Duration 1 year if criteria met Renewal requires reassessment Cigna Policy

Coding Basics: Medical vs. Pharmacy Benefit

Pemazyre (pemigatinib) is an oral oncology drug that typically falls under the medical pharmacy benefit rather than traditional retail pharmacy coverage. This distinction affects how it's billed and where patients receive it.

Medical Benefit Path

  • Coverage: Through Cigna's medical benefit (like infusion drugs)
  • Dispensing: Specialty pharmacy or "white bagging" to infusion centers
  • Billing: Uses NDC codes since no permanent HCPCS J-code exists
  • Prior Auth: Required through Cigna's oncology team

Coding Requirements

Since Pemazyre lacks a permanent HCPCS J-code, billing relies on:

  • NDC codes for the specific strengths
  • Temporary S-codes if required by the payer
  • Medical benefit processing through specialty pharmacy networks
Tip: Verify with Cigna whether they prefer NDC billing or temporary HCPCS codes for oral oncology agents.

ICD-10 Diagnosis Codes and Documentation

Accurate diagnosis coding is critical for Pemazyre approval. The primary conditions treated are cholangiocarcinoma with FGFR2 alterations and myeloid/lymphoid neoplasms with FGFR1 rearrangements.

Primary ICD-10 Codes

Condition ICD-10 Code Documentation Requirements
Intrahepatic cholangiocarcinoma C22.1 Specify FGFR2 fusion status in notes
Myeloid/lymphoid neoplasm with FGFR1 C92.5 or C94.3 Document specific FGFR1 rearrangement
Metastatic disease C78.xx (site-specific) Include primary and metastatic sites

Supporting Documentation Words

Include these phrases in clinical notes to strengthen medical necessity:

  • "FGFR2 fusion-positive intrahepatic cholangiocarcinoma"
  • "Previously treated with gemcitabine/cisplatin with disease progression"
  • "Candidate for targeted FGFR inhibitor therapy"
  • "No contraindications to pemigatinib treatment"

Product Coding: NDC Numbers and Billing Units

Pemazyre is available in three strengths, each with specific NDC numbers for billing purposes.

NDC Codes and Strengths

  • 4.5 mg tablets: NDC 50881-026-01
  • 9 mg tablets: NDC 50881-027-01
  • 13.5 mg tablets: NDC 50881-028-01

Monthly Supply Calculation

Standard dosing is 13.5 mg once daily for 14 days, followed by 7 days off in 21-day cycles:

  • Active treatment days: 14 tablets per cycle
  • Monthly supply: Approximately 42 tablets (14 tablets × 3 cycles)
  • Billing units: Submit as tablet count, not mg strength

Dose Modifications

For patients requiring dose reductions due to toxicity or drug interactions:

  • 9 mg daily: Reduce from 13.5 mg for moderate toxicity
  • 4.5 mg daily: Further reduction for severe toxicity or CYP interactions
Note: Document the clinical reason for any dose modification in the PA request.

Clean Prior Authorization Request

A successful Cigna PA for Pemazyre requires specific elements arranged logically. Here's the anatomy of a clean request:

Essential Components

  1. Patient Demographics
    • Full name, DOB, Cigna member ID
    • Prescriber NPI and contact information
  2. Clinical Justification
    • Primary diagnosis with ICD-10 code (C22.1 for cholangiocarcinoma)
    • FGFR testing results with specific fusion/rearrangement identified
    • Prior therapy history with dates and outcomes
  3. Treatment Plan
    • Dosing: 13.5 mg daily × 14 days, 7 days off, 21-day cycles
    • Duration of requested coverage (typically 3-6 months initially)
    • Ophthalmologic monitoring schedule
  4. Supporting Evidence
    • FDA approval indication reference
    • NCCN guideline citation (verify current version)
    • Molecular testing report

Sample Request Structure

Patient: [Name], DOB [Date], Member ID [Number]
Diagnosis: Intrahepatic cholangiocarcinoma (C22.1) with FGFR2-BICC1 fusion
Prior therapy: Gemcitabine/cisplatin (start date - end date, reason for discontinuation)
Requested: Pemazyre 13.5 mg daily × 14 days, 7 days off, 21-day cycles
Monitoring: Ophthalmologic exams every 2 months per FDA label

Common Coding Pitfalls to Avoid

Several frequent errors can delay or derail Pemazyre approval:

Unit Conversion Errors

  • Wrong: Billing by mg content instead of tablet count
  • Right: Submit quantity as number of tablets dispensed

Missing FGFR Documentation

  • Wrong: Generic "cholangiocarcinoma" without biomarker status
  • Right: Specific fusion identified (e.g., "FGFR2-BICC1 fusion detected by NGS")

Incorrect Benefit Category

  • Wrong: Submitting to retail pharmacy benefit
  • Right: Processing through medical/specialty pharmacy benefit

Incomplete Monitoring Plan

  • Wrong: No mention of ophthalmologic surveillance
  • Right: Detailed eye exam schedule per FDA requirements
Clinician Corner: Include the specific FGFR testing method (NGS, FISH) and laboratory name in your documentation. Cigna may request the full molecular report for review.

Verification with Cigna Resources

Before submitting your PA, verify current requirements through official Cigna channels:

Provider Resources

  • Cigna Provider Portal: Check current PA forms and requirements
  • Provider Services: Call to confirm specialty pharmacy networks
  • Medical Policy: Review Cigna's Pemazyre policy for updates

Patient Verification Steps

  1. Confirm Cigna plan covers specialty oncology drugs
  2. Check if prior authorization was already submitted
  3. Verify specialty pharmacy network participation
  4. Review copay/coinsurance responsibilities

Appeals Process in Pennsylvania

If Cigna denies your Pemazyre request, Pennsylvania offers robust appeal options with strong patient success rates.

Internal Appeals (Required First Step)

  • Timeline: Must appeal within 180 days of denial
  • Process: Submit through Cigna member/provider portal
  • Documentation: Include additional clinical evidence, peer-reviewed studies
  • Decision: Typically within 15-30 days

Pennsylvania External Review

Pennsylvania's Independent External Review program, launched in 2024, has achieved a 50% overturn rate for denied claims.

Eligibility: Commercial insurance plans (excludes self-funded employer plans) Timeline: Request within 4 months of final internal denial Process: Submit online at pa.gov/services/insurance Decision: Within 45 days (72 hours for expedited cases) Cost: Free to patients

Pennsylvania Advantage: The state's external review program has helped over 250 patients get coverage for initially denied treatments in its first year.

When preparing for external review, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and payer-specific requirements—exactly what's needed for complex specialty drug appeals like Pemazyre.

Pre-Submission Audit Checklist

Review these items before submitting your Pemazyre PA to Cigna:

Clinical Documentation

  • FGFR testing completed with specific fusion/rearrangement identified
  • Prior therapy documented with dates and outcomes
  • Current disease status and treatment goals stated
  • Ophthalmologic monitoring plan included

Coding Accuracy

  • Correct ICD-10 code for primary diagnosis (C22.1 for cholangiocarcinoma)
  • Appropriate NDC code for prescribed strength
  • Quantity calculated correctly for 21-day cycles
  • Medical benefit processing pathway confirmed

Administrative Details

  • All required PA form fields completed
  • Prescriber signature and date included
  • Patient demographics match insurance card exactly
  • Supporting documents attached (lab reports, imaging, prior therapy records)

FAQ

How long does Cigna prior authorization take for Pemazyre in Pennsylvania? Cigna processes standard PA requests within 72 hours and urgent requests within 24-48 hours. Complex cases requiring peer review may take up to 15 days.

What if Pemazyre is non-formulary on my Cigna plan? You can request a formulary exception through the same PA process. Include documentation that formulary alternatives are inappropriate or have failed.

Can I get an expedited appeal if my condition is urgent? Yes. Both Cigna internal appeals and Pennsylvania external review offer expedited timelines (24-72 hours) when health is at immediate risk.

Does step therapy apply to Pemazyre in Pennsylvania? Cigna requires documentation of prior systemic therapy, but specific step therapy protocols vary by plan. Your oncologist should document why standard chemotherapy was inadequate.

What financial assistance is available for Pemazyre? Incyte offers the IncyteCARES program with copay assistance and patient support services. Eligibility requirements and coverage details are available on their website.

How do I find out if my employer plan is self-funded? Check your insurance card or benefits summary for language about "administrative services" or contact HR. Self-funded plans aren't eligible for Pennsylvania's external review program.

Sources & Further Reading

For patients and families navigating complex specialty drug approvals, Counterforce Health provides comprehensive support in turning denials into successful appeals. Their evidence-based approach has helped countless patients access life-changing treatments through targeted rebuttal strategies.

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 additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

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