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

How to Get Photrexa (Riboflavin) Covered by Cigna in New York: Complete Cost-Cutting Guide

Answer Box: Getting Photrexa Covered by Cigna in New York

Cigna requires prior authorization for Photrexa (riboflavin ophthalmic solution) and classifies it as a specialty medication in Tier 4 or 5. Your out-of-pocket costs can range from hundreds to thousands of dollars per eye, but multiple cost-reduction strategies exist.

Three immediate steps:

  1. Request prior authorization through your ophthalmologist with documented progressive keratoconus evidence
  2. Apply for Glaukos patient assistance if you have commercial insurance (not Medicare/Medicaid)
  3. Verify Accredo specialty pharmacy coordination for dispensing

If denied: New York offers robust external appeal rights through the Department of Financial Services within 4 months of final denial.

Table of Contents

  1. What Drives Photrexa Costs with Cigna
  2. Benefit Investigation: What to Ask
  3. Manufacturer and Financial Assistance
  4. Requesting Formulary Tier Exceptions
  5. Specialty Pharmacy Coordination
  6. Appealing Coverage Denials
  7. Annual Renewal Planning
  8. Conversation Scripts
  9. New York External Appeal Rights
  10. FAQ

What Drives Photrexa Costs with Cigna

Understanding Cigna's benefit design helps you plan for Photrexa expenses. The total procedure typically costs $2,500-$4,000 per eye, but your portion depends on several factors.

Coverage Structure

Specialty Drug Classification: Cigna categorizes Photrexa as a specialty medication, requiring dispensing through Accredo specialty pharmacy. This typically places it in Tier 4 or 5 with higher cost-sharing—often 30-50% coinsurance rather than fixed copays.

Medical vs. Pharmacy Benefit: Photrexa may be covered under your medical benefit (as part of the corneal cross-linking procedure) rather than pharmacy benefit, which can affect your deductible and out-of-pocket calculations.

Prior Authorization Requirements

Cigna requires prior authorization for Photrexa, with standard review taking 3-5 business days. Your ophthalmologist must demonstrate medical necessity through:

  • Serial corneal topography showing ≥1.0 diopter increase in maximum keratometry (Kmax)
  • Documentation of failed conservative treatments (contact lenses, glasses)
  • Proper diagnosis coding (ICD-10 H18.621 for progressive keratoconus)

Benefit Investigation: What to Ask

Before starting treatment, gather specific information about your Cigna coverage to avoid surprises.

Essential Questions for Cigna Customer Service

Call the member services number on your insurance card and ask:

  1. "Is Photrexa covered under my medical or pharmacy benefit?"
  2. "What's my specialty drug coinsurance percentage and annual out-of-pocket maximum?"
  3. "Does my plan require step therapy before Photrexa approval?"
  4. "What's the prior authorization timeline for ophthalmology procedures?"
  5. "Which specialty pharmacy must I use—Accredo or another?"

Information to Record

Document these details for reference:

  • Your member ID and group number
  • Specialty drug tier and cost-sharing percentage
  • Deductible remaining and out-of-pocket maximum
  • Prior authorization reference number (once submitted)
  • Customer service representative name and call date

Manufacturer and Financial Assistance

Several programs can significantly reduce your Photrexa costs, but eligibility varies by insurance type.

Glaukos Patient Savings Program

The Glaukos iLink Patient Savings Program provides copay assistance for commercially insured patients:

Eligibility Requirements:

  • Must have commercial insurance (private health insurance)
  • Not eligible for Medicare, Medicaid, TRICARE, or VA coverage
  • Prescribed Photrexa as part of FDA-approved iLink corneal cross-linking

How to Apply:

  • Application handled through your ophthalmologist's office
  • Provide insurance information and Explanation of Benefits (EOB)
  • Contact Glaukos iLink Program: 1-844-528-3376
Note: Government insurance beneficiaries cannot use manufacturer copay cards due to federal anti-kickback regulations.

Foundation Assistance Programs

If you're not eligible for manufacturer assistance, consider these options:

  • Patient Advocate Foundation (PAF) Co-Pay Relief Program
  • HealthWell Foundation (for specific conditions)
  • National Organization for Rare Disorders (NORD) Patient Assistance Programs

Case Management Services

Cigna's case management through Accredo includes financial counseling to identify additional assistance programs and coordinate benefits.

Requesting Formulary Tier Exceptions

If Photrexa's high tier placement creates affordability barriers, you can request a formulary exception to lower your costs.

When to Request an Exception

Consider a tier exception if:

  • Your out-of-pocket costs exceed $500 per treatment
  • You've previously used Photrexa successfully
  • Alternative treatments have failed or caused adverse effects

Documentation Requirements

Your physician must certify in writing that:

  • You've previously used a formulary drug that was detrimental or ineffective
  • The requested drug is likely to be more effective for your condition
  • Clinical evidence supports the medical necessity

Timeline and Process

Cigna reviews formulary exceptions within 72 hours of receiving complete documentation. For urgent cases, expedited review provides decisions within 24 hours.

Specialty Pharmacy Coordination

Photrexa must be dispensed through Cigna's specialty pharmacy network, primarily Accredo (under Express Scripts management).

Dispensing Requirements

Provider Coordination: Accredo ships Photrexa directly to your ophthalmologist's office for in-office administration, not to your home address.

Prescription Processing: Your doctor can submit prescriptions to Accredo via:

  • Online provider portal
  • Fax: (verify current number with Accredo)
  • Phone: 844-516-3319 (Physician Service Center)

Patient Support Services

Accredo provides:

  • Condition-specific clinical support from specialty pharmacists
  • Scheduling coordination with your provider
  • Financial assistance program navigation
  • 24/7 patient support access

Appealing Coverage Denials

If Cigna denies your Photrexa prior authorization, New York residents have strong appeal rights with specific timelines.

Internal Appeals with Cigna

Timeline: You have 180 days from the denial date to file an internal appeal.

Required Documentation:

  • Original denial letter
  • Additional clinical evidence (updated topography, progression photos)
  • Medical necessity letter from your ophthalmologist
  • Relevant medical literature supporting treatment

Submission: File appeals through Cigna's member portal or mail to the address on your denial letter.

Peer-to-Peer Review

Request a peer-to-peer review where your ophthalmologist discusses the case directly with Cigna's medical director. This often resolves denials based on missing clinical context.

Annual Renewal Planning

Photrexa coverage can change annually, so plan ahead for potential cost fluctuations.

What Can Change

  • Formulary tier placement and cost-sharing percentages
  • Prior authorization requirements
  • Preferred specialty pharmacy networks
  • Step therapy protocols

Renewal Checklist

October-November:

  • Review your plan's 2025 formulary for Photrexa placement
  • Compare alternative plan options during open enrollment
  • Verify continued Glaukos patient assistance eligibility

December:

  • Confirm Accredo remains your plan's specialty pharmacy
  • Update financial assistance applications for the new year

Conversation Scripts

Calling Cigna Customer Service

"Hi, I'm calling about prior authorization for Photrexa, a specialty medication for corneal cross-linking. My member ID is [number]. Can you tell me the current status of PA request [reference number] and what additional documentation might be needed?"

Requesting Peer-to-Peer Review

"We'd like to request a peer-to-peer review for our Photrexa denial. The patient has documented progressive keratoconus with failed conservative management. When can we schedule a call with your medical director?"

New York External Appeal Rights

New York offers some of the nation's strongest insurance appeal protections through the Department of Financial Services (DFS).

When to File External Appeals

After Cigna issues a final adverse determination on your internal appeal, you have 4 months to request external review through New York DFS.

Process and Timeline

New York's External Appeal program assigns independent medical experts to review your case. Their decision is binding on Cigna.

Expedited Appeals: For urgent cases, New York provides decisions within 72 hours (24 hours for urgent drug denials) when your health is at serious risk.

Cost: Maximum $25 filing fee, waived for financial hardship or Medicaid enrollees.

Additional Support

Community Health Advocates (CHA): Free counseling on insurance denials and appeals

  • Helpline: 888-614-5400
  • Assistance with filing appeals and understanding your rights

FAQ

How long does Cigna prior authorization take for Photrexa in New York? Standard review takes 3-5 business days. Expedited review (for urgent cases) provides decisions within 24-72 hours.

What if Photrexa isn't on Cigna's formulary? You can request a formulary exception with physician documentation. Cigna reviews these requests within 72 hours of complete submission.

Can I use manufacturer copay assistance with Cigna? Yes, if you have commercial Cigna coverage. Medicare and Medicaid beneficiaries are not eligible for manufacturer copay programs.

Does step therapy apply to Photrexa? Some Cigna plans require documentation of failed conservative treatments (glasses, contact lenses) before approving Photrexa for progressive keratoconus.

What happens if I move from New York to another state? Your Cigna coverage terms generally remain the same, but state appeal rights and external review processes will change based on your new state's regulations.

How do I coordinate between my doctor and Accredo specialty pharmacy? Your ophthalmologist's office submits prescriptions directly to Accredo, which then coordinates delivery timing with your scheduled procedure date.

Counterforce Health: Streamlining Your Appeal Process

When facing complex prior authorization requirements or coverage denials, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific denial basis—whether PA criteria, step therapy, or medical necessity—then drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

For Photrexa appeals, this means incorporating FDA labeling, corneal cross-linking guidelines, and the specific progression documentation Cigna requires, all formatted to meet New York's procedural requirements and deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current policy terms with Cigna and consult your healthcare provider for medical decisions. For personalized assistance with New York insurance appeals, contact Community Health Advocates at 888-614-5400.

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