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

How to Get Prolastin-C Covered by Cigna in Virginia: Complete Prior Authorization Guide

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

Prolastin-C requires prior authorization from Cigna in Virginia. To get approved, you need: (1) documented alpha1-antitrypsin deficiency with severe genotype (Pi*ZZ), (2) AAT serum level <11 mcmol/L, and (3) lung function evidence (FEV1 <65% predicted or accelerated decline). First step today: Have your pulmonologist submit prior authorization through Cigna's provider portal or call 1-800-835-3784 for Accredo specialty pharmacy enrollment. If denied, Virginia's Bureau of Insurance offers external review within 120 days of final denial. Virginia external review forms here.

Table of Contents

Plan Types & Network Requirements

Cigna offers three main plan types in Virginia, each with different requirements for accessing Prolastin-C:

HMO Plans:

  • Require primary care physician (PCP) referral to pulmonologist
  • Limited network of providers
  • No out-of-network coverage except emergencies
  • Lowest premiums but most restrictive access

PPO Plans:

  • No referral required for specialists
  • Largest provider network
  • Out-of-network coverage available at higher cost
  • Highest premiums but maximum flexibility

EPO Plans:

  • No referrals needed
  • Medium-sized network
  • No out-of-network coverage except emergencies
  • Mid-range premiums
Note: All Cigna plans require specialty medications like Prolastin-C to be filled through Accredo specialty pharmacy for coverage.

Formulary Status & Tier Placement

Prolastin-C is classified as a Tier 4 specialty medication on Cigna's formulary as of 2025. This placement means:

  • Higher cost-sharing than standard medications
  • Must be dispensed through Accredo specialty pharmacy
  • Prior authorization required before coverage
  • Limited to 30-day supplies initially

Preferred Alternatives Under Step Therapy: According to Cigna's coverage policy, effective July 2025:

Product Step Therapy Required
Glassia No (preferred first-line)
Prolastin-C No (preferred first-line)
Zemaira No
Aralast NP Yes (must fail both Glassia AND Prolastin-C)

Prior Authorization Requirements

Medical Necessity Criteria

To qualify for Prolastin-C coverage, patients must meet Cigna's specific criteria:

Required Documentation:

  • Age ≥18 years
  • Alpha1-antitrypsin serum concentration <11 mcmol/L (<80 mg/dL by radial immunodiffusion or <57 mg/dL by nephelometry)
  • Genotyping confirming ZZ, (null)(null), Z(null), SZ, or other severe disease-causing alleles
  • Prescription by or consultation with pulmonologist or dermatologist

Lung Function Requirements (one of the following):

  • FEV1 <65% of predicted at baseline, OR
  • Documented accelerated decline (FEV1 decline >100 mL/year or DLCO decline >15% per year), OR
  • Supplemental oxygen requirement

Standard dosing: 60 mg/kg intravenously once weekly

Specialty Pharmacy Setup

Accredo Enrollment Process

Cigna requires Prolastin-C to be dispensed through Accredo specialty pharmacy. Here's how to get started:

Three Ways to Initiate:

  1. Online: Log into myCigna account, find eligible medications, click "Switch Today"
  2. Provider: Have your doctor send 90-day prescription electronically to Express Scripts Home Delivery
  3. Phone: Call 1-800-835-3784 - Express Scripts will contact your provider

Required Information:

  • Cigna ID card
  • Provider contact information
  • Complete medication name and dosing
  • Prior authorization approval confirmation
Tip: Accredo provides specialty-trained pharmacists and nurses for ongoing support throughout your treatment.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
What: Lab results (AAT level, genotype), spirometry (FEV1), medical records
Timeline: 1-2 days

2. Specialist Consultation

Who: Pulmonologist or dermatologist
What: Clinical evaluation and prescription
Timeline: 1-2 weeks (depending on appointment availability)

3. Prior Authorization Submission

Who: Prescriber's office
What: Submit PA through Cigna provider portal or CoverMyMeds
Timeline: Submit within 24-48 hours of prescription

4. Cigna Review Process

Who: Cigna utilization management
What: Medical necessity review
Timeline: 5-7 business days for standard review

5. Approval and Pharmacy Setup

Who: Patient
What: Contact Accredo for enrollment and delivery setup
Timeline: 2-3 days after approval

6. First Infusion Coordination

Who: Accredo nursing team
What: Home infusion setup and training
Timeline: 1-2 weeks from pharmacy enrollment

7. Ongoing Management

Who: Patient and care team
What: Weekly infusions and monitoring
Timeline: Ongoing with annual reauthorization

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genotype Submit genetic testing results Pi*ZZ or equivalent severe allele confirmation
Insufficient lung function Provide complete pulmonary function tests FEV1 <65% or documented decline >100 mL/year
Inadequate AAT level Resubmit with proper lab method AAT <11 mcmol/L by specified testing method
Wrong prescriber Get pulmonologist consultation Prescription or consultation note from specialist
Incomplete prior trials Document previous therapy failures Records of tried treatments and reasons for discontinuation

Virginia Appeals Process

If Cigna denies your Prolastin-C request, Virginia offers robust appeal rights through the State Corporation Commission's Bureau of Insurance.

Internal Appeals (Required First)

  • Timeline: 180 days from denial notice
  • Levels: First and second-level internal review
  • Expedited: Available for urgent cases
  • How: Submit through myCigna portal or call member services

External Review (After Internal Appeals)

  • Timeline: 120 days from final internal denial
  • Process: Virginia Bureau of Insurance assigns Independent Review Organization
  • Standard Review: 45 days for decision
  • Expedited Review: 72 hours for urgent medical necessity
  • Forms: Form 216-A External Review Request
  • Cost: Free to consumers
Virginia Advantage: The state allows expedited external review for certain treatments without exhausting all internal appeals first.

Contact Information:

  • Virginia Bureau of Insurance: 1-877-310-6560
  • Managed Care Ombudsman: Same number for additional support

When dealing with insurance coverage challenges, Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed, targeted rebuttals aligned to each plan's specific requirements. Their platform helps patients and clinicians navigate complex prior authorization processes for specialty medications like Prolastin-C.

Cost Considerations

Cigna Coverage Structure

  • Tier 4 Specialty: Higher copay/coinsurance
  • Deductible: May apply before coverage begins
  • Annual Cost: AAT therapy can exceed $80,000 annually

Financial Assistance Options

  • Grifols Patient Assistance: Check manufacturer programs
  • State Programs: Virginia expanded Medicaid may provide additional coverage options
  • Foundation Grants: Various rare disease foundations offer support
Important: Always verify current copay and deductible amounts through myCigna before starting therapy.

FAQ

How long does Cigna prior authorization take in Virginia? Standard review takes 5-7 business days. Expedited review (when medically urgent) takes 72 hours. Submit complete documentation to avoid delays.

What if Prolastin-C is non-formulary on my specific plan? Request a formulary exception through your prescriber. Include clinical rationale for why preferred alternatives aren't suitable.

Can I request an expedited appeal in Virginia? Yes. If your doctor certifies that waiting could jeopardize your health, Virginia offers 72-hour expedited external review for medical necessity denials.

Does step therapy apply if I've failed therapies outside Virginia? Yes. Document previous treatment failures with medical records, regardless of where therapy was attempted. Cigna accepts out-of-state treatment history.

What happens if my appeal is denied? Virginia's external review decision is binding on both you and Cigna. If approved, Cigna must provide coverage within 1-3 days. If denied, consider legal consultation.

How do I switch from another AAT therapy to Prolastin-C? Work with your pulmonologist to document medical necessity for the switch. Common reasons include infusion site reactions, scheduling conflicts, or clinical response differences.

From Our Advocates

We've seen many Virginia patients successfully obtain Prolastin-C coverage after initial denials by ensuring their pulmonologist includes specific FEV1 decline rates and detailed genotype reports in the appeal. The key is presenting a complete clinical picture that clearly demonstrates medical necessity under Cigna's published criteria.

Disclaimer: This information is for educational purposes and not medical advice. Always consult your healthcare provider for medical decisions and verify current insurance requirements through official channels.

For additional support with complex insurance appeals and prior authorization challenges, Counterforce Health provides specialized assistance in creating compelling, evidence-based appeals that align with payer-specific requirements.

Sources & Further Reading

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