By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

How to Get Photrexa Covered by Cigna in Ohio: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Photrexa Covered by Cigna in Ohio

Yes, Cigna covers Photrexa (riboflavin ophthalmic solution) for FDA-approved epithelium-off corneal cross-linking in progressive keratoconus. Your ophthalmologist must submit prior authorization through Cigna's provider portal with documented progression evidence (Kmax increase ≥1.0D, pachymetry thinning, topography changes over 3-12 months). If denied, you have 180 days to file internal appeals, then Ohio external review through the Department of Insurance. Start today: Have your doctor gather serial corneal imaging and submit the PA request with complete progression documentation.

Table of Contents

Coverage Basics: Is Photrexa Covered?

Cigna covers Photrexa (riboflavin ophthalmic solution) when used with the FDA-approved iLink® system for epithelium-off corneal collagen cross-linking in patients with progressive keratoconus or post-refractive surgery corneal ectasia. This coverage applies to most Cigna commercial plans in Ohio.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Photrexa prescriptions Cigna Provider Portal
Formulary Status Specialty tier medication Plan formulary documents
Step Therapy May require documented failure of conservative management Clinical policy guidelines
Site of Care Must use approved ophthalmology facility Provider network directory
Diagnosis Codes H18.621-H18.629 (keratoconus, unstable, by laterality) ICD-10 coding manual
Important: Cigna excludes epithelium-on (epi-on) corneal cross-linking as it's not FDA-approved and is considered experimental.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Doctor Gathers Documentation (1-2 days)
    • Serial corneal topography/tomography (minimum 3 months apart)
    • Pachymetry measurements showing progression
    • Complete clinical notes with progression evidence
  2. Submit PA Request (Same day)
    • Use Cigna provider portal
    • Include all required clinical documentation
    • Specify FDA-approved iLink® system usage
  3. Cigna Review (24-72 hours)
    • Non-urgent: 72 hours maximum
    • Urgent cases: 24 hours maximum
    • Auto-approval if Cigna doesn't respond within timeframe
  4. Approval Notification
    • Sent to prescriber and patient
    • Includes authorization number and duration
  5. Prescription to Accredo (1-2 days)
    • Cigna requires specialty medications through Accredo
    • Doctor sends prescription electronically or by fax

Required Clinical Documentation

Your ophthalmologist must provide:

  • Progression Evidence: Kmax increase ≥1.0 diopter over 12-24 months
  • Pachymetry Changes: Corneal thinning ≥10 microns at thinnest point
  • Topographic Progression: Serial maps showing worsening ectatic pattern
  • Specific ICD-10 Codes: H18.621 (right eye) or H18.622 (left eye) for unstable keratoconus
  • Treatment History: Documentation of conservative management attempts

Timeline and Urgency

Standard Timeline

  • PA Submission to Decision: 72 hours maximum
  • Urgent/Expedited Review: 24 hours maximum
  • Appeal Response: 60 days for internal review

When to Request Expedited Review

  • Rapid keratoconus progression threatening vision
  • Risk of corneal perforation or scarring
  • Patient experiencing significant visual deterioration

Contact Cigna at 877-826-7657 to request expedited review with supporting clinical documentation.

Clinical Criteria and Documentation

Medical Necessity Requirements

Cigna requires documentation of progressive keratoconus with objective evidence:

Kmax Changes:

  • Increase of ≥1.0 diopter over 12-24 months
  • Must exceed measurement variability of imaging device
  • Requires minimum two separate measurements

Pachymetry Documentation:

  • Progressive thinning ≥10 microns at thinnest point
  • Serial measurements using same device (Pentacam preferred)
  • Clear documentation of measurement locations

Topographic Evidence:

  • Worsening inferior or asymmetric steepening
  • Increased irregular astigmatism patterns
  • Anterior/posterior elevation changes over time

Clinician Corner: Medical Necessity Letter Checklist

✅ Problem Statement: "Patient has progressive keratoconus with documented worsening over X months"

✅ Objective Evidence: Specific Kmax, pachymetry, and topographic changes with dates

✅ Prior Treatments: Conservative management attempts (specialty contact lenses, etc.)

✅ Clinical Rationale: Why cross-linking is necessary to halt progression

✅ FDA Approval: Reference to iLink® system FDA approval for this indication

✅ Treatment Plan: Specific procedure details and expected outcomes

Costs and Specialty Pharmacy

Patient Costs with Cigna

  • Specialty Drug Copay: 20% coinsurance, maximum $50 per 34-day supply
  • Procedure Costs: Varies by plan; typically covered after PA approval
  • Total Out-of-Pocket: Depends on deductible and annual maximums

Accredo Specialty Pharmacy Process

Cigna requires Photrexa dispensing through Accredo:

  1. Prescription Transfer: Doctor sends prescription to Accredo
  2. Patient Contact: Accredo calls to verify information and schedule delivery
  3. Counseling Services: 24/7 access to specialty-trained pharmacists
  4. Delivery Options: Home, office, or clinic delivery available

Contact Accredo: 877-826-7657

Financial Assistance Options

  • Glaukos Patient Assistance: Check manufacturer website for current programs
  • Foundation Grants: Patient Advocate Foundation, NeedyMeds
  • State Programs: Ohio pharmaceutical assistance programs (verify eligibility)

Denials and Appeals in Ohio

Common Denial Reasons and Solutions

Denial Reason How to Fix
Insufficient progression documentation Submit additional serial imaging with clear progression metrics
Non-FDA approved method Confirm iLink® system usage in resubmission
Missing laterality codes Use specific ICD-10: H18.621 (right) or H18.622 (left)
Inadequate prior therapy documentation Provide records of conservative management attempts

Appeals Process in Ohio

Internal Appeals (Cigna):

  • Deadline: 180 days from denial
  • Submit to: Cigna appeals department via provider portal
  • Response Time: 60 days maximum
  • Required Documents: Denial letter, clinical notes, additional evidence

Ohio External Review:

  • When Available: After exhausting internal appeals
  • Deadline: 180 days from final internal denial
  • Process: Ohio Department of Insurance assigns Independent Review Organization
  • Contact: Ohio DOI Consumer Services: 1-800-686-1526

Appeals Playbook for Ohio Residents

  1. File Internal Appeal (Within 180 days)
    • Gather all denial letters and EOBs
    • Obtain additional clinical documentation
    • Submit via Cigna appeals process
  2. Prepare External Review (If internal appeal denied)
    • Request external review form from Ohio Department of Insurance
    • Compile complete medical record
    • Include peer-reviewed literature supporting medical necessity
  3. IRO Review (30 days standard, 72 hours expedited)
    • Independent medical experts review case
    • Decision is binding on Cigna
    • If approved, Cigna must cover procedure
From Our Advocates: We've seen Ohio external reviews successfully overturn Cigna denials for corneal cross-linking when providers submitted complete progression documentation with peer-reviewed studies. The key is demonstrating clear medical necessity with objective measurements that exceed normal test variability.

Renewals and Re-authorization

When Re-authorization is Needed

  • One-time procedure: Photrexa cross-linking typically doesn't require renewal
  • Bilateral treatment: Separate PA may be needed for second eye
  • Plan changes: New authorization required if switching Cigna plans

Documentation for Second Eye

If treating both eyes separately:

  • Document progression in the second eye
  • Provide updated clinical assessment
  • Include results/outcomes from first eye treatment

Common Problems and Solutions

Portal and Submission Issues

Problem: Cigna provider portal not accepting PA submission Solution: Contact Cigna provider services at 1-800-88-CIGNA for technical support

Problem: Missing prior authorization forms Solution: Download current forms from Cigna provider resources

Documentation Gaps

Problem: Insufficient progression documentation Solution: Schedule additional corneal imaging if >6 months since last measurement

Problem: Wrong diagnostic codes Solution: Use laterality-specific codes (H18.621/H18.622) for unstable keratoconus

FAQ: Most Asked Questions

Q: How long does Cigna prior authorization take in Ohio? A: Maximum 72 hours for standard requests, 24 hours for urgent cases. If Cigna doesn't respond within these timeframes, the request may be automatically approved.

Q: What if Photrexa is non-formulary on my plan? A: Request a formulary exception through your doctor with medical necessity documentation. Cigna has processes for non-formulary drug approvals when medically necessary.

Q: Can I request an expedited appeal in Ohio? A: Yes, for urgent medical situations. Contact Cigna appeals department and Ohio DOI if rapid progression threatens vision.

Q: Does step therapy apply if I tried treatments outside Ohio? A: Yes, documented treatment history from any state counts toward step therapy requirements. Ensure all prior therapy records are included.

Q: What happens if my appeal is denied by Cigna? A: You can request Ohio external review through the Department of Insurance. An independent medical expert will review your case, and their decision is binding on Cigna.

Q: How much will Photrexa cost with Cigna coverage? A: Typically 20% coinsurance with a $50 maximum copay for the medication. Total procedure costs depend on your specific plan benefits.

Getting personalized help with your Photrexa approval: Counterforce Health helps patients and clinicians navigate complex prior authorization processes by analyzing denial letters, identifying specific payer requirements, and drafting evidence-backed appeals. Their platform specializes in turning insurance denials into targeted rebuttals aligned with each plan's specific criteria, potentially saving weeks in the approval process.

For additional support with your Cigna appeal in Ohio, consider working with Counterforce Health to ensure your documentation meets all payer-specific requirements and maximizes your chances of approval.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage policies vary by plan and may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For official Ohio insurance regulations and appeal procedures, contact the Ohio Department of Insurance.

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