By Counterforce Health Team in Prolastin-C (alpha1-proteinase inhibitor) —

How to Get Prolastin-C Covered by Cigna in Georgia: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Prolastin-C Covered by Cigna in Georgia

Cigna requires prior authorization for Prolastin-C with documented alpha1-antitrypsin deficiency (AAT <80 mg/dL) and baseline pulmonary function tests. Submit PA via CoverMyMeds or provider portal with genotype confirmation and clinical notes. If denied, you have 180 days for internal appeals, then 60 days for Georgia external review through the Department of Insurance. Prolastin-C is typically preferred over alternatives like Zemaira, reducing step therapy requirements.

First step today: Contact your prescriber to initiate the Cigna prior authorization process and verify your AAT levels meet coverage criteria.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Understanding Your Cigna Benefits
  4. Cost-Saving Assistance Options
  5. When Prior Authorization Gets Denied
  6. Georgia Appeals Process
  7. Specialty Pharmacy Coordination
  8. Annual Renewal Planning
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all AAT therapies Cigna formulary, provider portal Cigna PA Forms
Diagnosis Confirmation AAT serum <80 mg/dL (11 μmol/L) Lab results, genotype testing Cigna Policy IP-0387
Age Requirement 18 years or older Patient chart FDA Prolastin-C Label
Pulmonary Function FEV1 <65% predicted OR decline >100 mL/year Spirometry reports Cigna Policy IP-0387
Preferred Status Prolastin-C is preferred (no step therapy) Cigna formulary 2025 Medicare Formulary
Site of Care Home or clinic infusion approved Provider enrollment form Accredo Enrollment

Step-by-Step: Fastest Path to Approval

  1. Confirm Diagnosis Requirements (Patient/Prescriber)
    • Verify AAT serum level <80 mg/dL and genotype results (Pi*ZZ, SZ, or null variants)
    • Obtain baseline spirometry showing FEV1 <65% predicted
    • Timeline: 1-2 weeks for lab results
    • Source: Cigna Coverage Policy
  2. Submit Prior Authorization (Prescriber)
    • Use CoverMyMeds portal or Cigna PA forms
    • Include: diagnosis codes, lab values, pulmonary function tests, weight for dosing
    • Timeline: Response within 5-7 business days
    • Source: CoverMyMeds Platform
  3. Coordinate Specialty Pharmacy (Prescriber/Patient)
    • ePrescribe to Accredo (NCPDP 4436920) as exclusive distributor
    • Select home or clinic administration on enrollment form
    • Timeline: 3-5 days for insurance verification
    • Source: Accredo Prolastin Enrollment
  4. Activate Patient Support (Patient)
    • Automatic enrollment in PROLASTIN DIRECT program
    • Contact 1-833-PHONEA1 for financial assistance up to $10,000/year
    • Timeline: Immediate upon prescription
    • Source: PROLASTIN DIRECT Program

Understanding Your Cigna Benefits

Formulary Tier and Coverage

Prolastin-C sits on Cigna's specialty tier with prior authorization requirements but preferred status over alternatives like Zemaira and Aralast NP. This means you won't face step therapy requirements that force you to try other alpha1-proteinase inhibitors first.

Note: Effective July 1, 2025, Cigna implemented stricter step therapy for non-preferred AAT therapies. Prolastin-C maintains its preferred status, making it the first-line choice for most patients.

Medical vs. Pharmacy Benefits

Alpha1-proteinase inhibitors typically fall under your medical benefit (Part B for Medicare) rather than prescription drug coverage, since they're administered by infusion. This affects your:

  • Deductible application
  • Coinsurance rates (often 20% after deductible)
  • Out-of-pocket maximums
  • Prior authorization pathway

Contact Cigna member services (number on your ID card) to confirm which benefit applies to your specific plan.

Cost-Saving Assistance Options

Manufacturer Support Programs

PROLASTIN DIRECT Program offers comprehensive financial assistance:

  • Up to $10,000 annually in copay assistance for eligible commercial insurance patients
  • Quick Start Program providing up to 8 weeks of no-cost therapy during PA processing
  • Insurance coordination with >90% success rate in obtaining coverage
  • Automatic enrollment when prescribed Prolastin-C Liquid

Contact: 1-833-PHONEA1 (746-6321) Source: PROLASTIN DIRECT Details

Important: Copay assistance typically applies only to commercial insurance, not Medicare or Medicaid plans.

Foundation and Grant Programs

  • Alpha-1 Foundation Patient Assistance Program
  • HealthWell Foundation may have grants for rare disease treatments
  • Patient Access Network (PAN) Foundation periodic funding for AAT deficiency

Verify current availability as funding cycles vary throughout the year.

State-Specific Resources

Georgia residents can access:

  • Georgia Department of Community Health for Medicaid/PeachCare appeals
  • Georgians for a Healthy Future consumer assistance and appeals guidance
  • Georgia Legal Services Program for low-income patients facing coverage denials

When Prior Authorization Gets Denied

Common Denial Reasons and Solutions

Denial Reason Required Documentation How to Submit
Insufficient diagnosis confirmation Genotype results, AAT level <80 mg/dL Fax to Cigna PA department with case number
Missing pulmonary function Spirometry showing FEV1 <65% predicted Include in medical necessity letter
Inadequate clinical notes Chart documentation of emphysema/COPD Provider peer-to-peer review
Dosing concerns Weight-based calculation (60 mg/kg weekly) Pharmacy consultation notes

Medical Necessity Letter Checklist

Your prescriber should include:

  • Diagnosis: Alpha1-antitrypsin deficiency with emphysema
  • Lab confirmation: Specific AAT level and genotype
  • Clinical rationale: Why augmentation therapy is appropriate
  • Guideline support: Reference to ATS/ERS clinical practice guidelines
  • Monitoring plan: Regular pulmonary function testing and clinical assessments

Georgia Appeals Process

Internal Appeals with Cigna

Timeline: 180 days from initial denial date Process:

  1. Submit written appeal with enhanced clinical documentation
  2. Request peer-to-peer review with Cigna medical director
  3. Include updated labs, imaging, or specialist consultations
  4. Response within 30 days for pre-service, 60 days for post-service

Expedited Appeals: Available if delay would seriously jeopardize your health or ability to regain maximum function.

External Review Through Georgia DOI

If Cigna's internal appeals are exhausted:

Deadline: 60 days from final internal denial letter Cost: Free to patients Process:

  1. Contact Georgia Department of Insurance Consumer Services: 1-800-656-2298
  2. Submit external review application with all denial letters and clinical records
  3. Independent review organization (IRO) assigned within 1 business day
  4. Decision rendered within 45 days (standard) or 72 hours (expedited)

Key advantage: External review decisions are binding on Cigna - they must cover the treatment if approved.

Source: Georgia External Review Process

When preparing for appeals, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to plan policies.

From our advocates: We've seen Georgia external reviews frequently overturn specialty drug denials when strong medical evidence demonstrates the treatment meets FDA-approved indications and clinical guidelines. The key is comprehensive documentation showing why the therapy is medically necessary for your specific condition.

Specialty Pharmacy Coordination

Accredo as Exclusive Distributor

Prolastin-C Liquid is only available through Accredo Specialty Pharmacy, Cigna's preferred specialty provider. This coordination offers several advantages:

  • Streamlined insurance verification and PA processing
  • Nurse-monitored home infusion services
  • Consistent therapy delivery and adherence support
  • Direct communication with your healthcare team

Home vs. Clinic Administration

Home Infusion Benefits:

  • 97% patient satisfaction rates
  • 40-60% lower costs compared to outpatient settings
  • Weekly 15-minute infusions with trained nurses
  • Vital sign monitoring and adverse reaction protocols

Clinic Administration:

  • May be required for initial doses or patients with reaction history
  • Allows immediate medical intervention if needed
  • Often preferred by physicians for complex cases

Both options are covered by Cigna when medically appropriate.

Annual Renewal Planning

Renewal Requirements (Effective 2025)

Start your renewal process 60-90 days before expiration with:

  • Updated Letter of Medical Necessity from prescriber
  • Current AAT levels and pulmonary function tests
  • Documentation of treatment response over past year
  • Any adverse events or dosing modifications
  • Continued confirmation of rare genotype variants

What Can Change

Monitor these factors that may affect coverage:

  • Formulary updates: Step therapy requirements for alternatives
  • Benefit design changes: Deductibles, coinsurance rates
  • Prior authorization criteria: Clinical requirements may evolve
  • Specialty pharmacy networks: Confirm Accredo remains in-network

For patients navigating these annual requirements, Counterforce Health's platform can help identify specific renewal criteria and draft comprehensive appeals if coverage is threatened.

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Prolastin-C in Georgia? A: Standard PA decisions are issued within 5-7 business days. Expedited requests (for urgent medical situations) are processed within 24-72 hours.

Q: What if Prolastin-C isn't on my Cigna formulary? A: You can request a formulary exception by demonstrating medical necessity. Include documentation that preferred alternatives are contraindicated or ineffective for your specific case.

Q: Can I get expedited coverage if I'm currently on therapy? A: Yes, if there's a gap in coverage that could seriously jeopardize your health. Contact Cigna immediately and request expedited processing, emphasizing the medical urgency.

Q: Does step therapy apply if I was stable on Prolastin-C before moving to Georgia? A: Continuation of therapy exceptions often apply. Provide documentation of your treatment history and clinical stability to support ongoing coverage.

Q: What happens if my appeal is denied at every level? A: After exhausting internal and external appeals, you can file a complaint with Georgia DOI Consumer Services or consult with a healthcare attorney about potential legal options.

Q: Are there income limits for manufacturer assistance programs? A: PROLASTIN DIRECT eligibility varies by program component. Commercial insurance patients typically qualify for copay assistance regardless of income, while grant programs may have financial criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and can change. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals and coverage denials, consider consulting with patient advocacy services or legal professionals specializing in healthcare coverage.

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