By Counterforce Health Team in Pyrukynd (mitapivat) —

How to Get Pyrukynd (Mitapivat) Covered by Cigna in Pennsylvania: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Pyrukynd Covered by Cigna in Pennsylvania

Cigna requires prior authorization for Pyrukynd (mitapivat) in Pennsylvania for adults with pyruvate kinase deficiency, confirmed by genetic testing (≥2 PKLR gene variants with ≥1 missense variant) and prescribed by a hematologist. You'll need hemoglobin ≤10 g/dL or ≥6 transfusions in 12 months, plus concurrent folic acid therapy. Submit through Cigna's provider portal with genetic confirmation, labs, and transfusion history. Standard review takes 72 hours; expedited review 24 hours for urgent cases. If denied, Pennsylvania's new external review program overturns ~50% of appeals.

First step today: Contact your hematologist to confirm genetic testing results and gather required documentation before submitting the PA request.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Pennsylvania-Specific Timelines
  7. If You Need More Information
  8. If Your Request Is Denied
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps patients with pyruvate kinase deficiency and their healthcare teams navigate Cigna's prior authorization process for Pyrukynd (mitapivat) in Pennsylvania. You'll learn exactly what documentation is required, how to submit your request, and what to do if you receive a denial.

Pyrukynd is an oral medication that activates pyruvate kinase in red blood cells, helping reduce hemolysis and transfusion requirements for adults with this rare genetic condition. At approximately $25,760 per carton for 28 days of therapy, proper insurance authorization is essential for most patients.

Who this helps:

  • Patients diagnosed with pyruvate kinase deficiency seeking Pyrukynd coverage
  • Hematologists and clinic staff managing prior authorization requests
  • Caregivers navigating the appeals process after a denial

Before You Start: Verify Your Coverage

Confirm Your Plan Type

First, verify whether you have a fully-insured Cigna plan or a self-funded employer plan. Pennsylvania's external review program applies to fully-insured commercial plans but may not cover self-funded plans. Check your insurance card or contact Cigna customer service at 1-800-88-CIGNA (1-800-882-4462).

Check Formulary Status

Pyrukynd is typically classified as a Tier 4 specialty medication on Cigna formularies, requiring prior authorization and dispensing through Express Scripts/Accredo specialty pharmacy. Verify your specific plan's formulary through the Cigna member portal or by calling the number on your insurance card.

Confirm Network Status

Ensure your hematologist is in-network with your Cigna plan. Out-of-network prescribers may face additional hurdles or require different authorization pathways.

Gather Required Documentation

Essential Clinical Documentation

Genetic Testing Results:

  • PKLR gene analysis showing ≥2 pathogenic variants
  • At least one variant must be missense (not homozygous p.R479H)
  • Acceptable tests include Mayo PKLRZ or Invitae PKLR panels

Laboratory Evidence:

  • Recent hemoglobin level (≤10 g/dL if limited transfusion history)
  • Baseline bilirubin, reticulocyte count, and LDH
  • Complete blood count with peripheral smear

Clinical History:

  • Transfusion records (≥6 transfusions in past 12 months if hemoglobin >10 g/dL)
  • Documentation of hemolytic anemia symptoms
  • Current folic acid supplementation prescription

Prescriber Requirements

Cigna requires prescription by a hematologist or in consultation with a hematologist. The prescriber must provide:

  • Board certification in hematology
  • Clinical assessment supporting medical necessity
  • Treatment plan including dosing and monitoring

Submit Your Prior Authorization Request

Submission Methods

Preferred: Cigna provider portal (fastest processing) Alternative: Fax to prior authorization department Phone: 866-435-5677 for urgent requests

Required Forms and Information

Submit a complete "request packet" including:

  • Completed Cigna prior authorization form
  • Prescriber attestation letter
  • Genetic testing report
  • Laboratory results (hemoglobin, bilirubin, reticulocytes)
  • Transfusion history documentation
  • Current medication list including folic acid
Tip: Request expedited review if the patient has immediate health risks or urgent medical needs. Include clinical justification for expedited processing.

Follow-Up and Tracking

Monitoring Your Request

Standard timeline: 72 hours for routine requests Expedited timeline: 24 hours for urgent cases

Track your request through:

  • Cigna provider portal (for healthcare teams)
  • Cigna member portal (for patients)
  • Phone follow-up with reference number

Sample Follow-Up Script

"Hello, I'm calling to check the status of a prior authorization request for Pyrukynd submitted on [date]. The reference number is [number]. Can you provide an update on the review timeline and any additional information needed?"

Document all interactions with reference numbers and representative names for your records.

Pennsylvania-Specific Timelines

Review and Appeals Process

Process Stage Standard Timeline Expedited Timeline Filing Deadline
Initial PA Review 72 hours 24 hours N/A
Level 1 Internal Appeal 30-60 days 72 hours 180 days from denial
Level 2 Internal Appeal 30-60 days 72 hours 60 days from Level 1 denial
PA External Review 45 days 72 hours 4 months from final denial

Pennsylvania's External Review Advantage

Since January 2024, Pennsylvania operates its own Independent External Review Program through the state Insurance Department. This program has achieved approximately 50% overturn rates for appealed denials, significantly higher than many other states.

The program covers medical necessity denials, experimental treatment denials, and other coverage disputes for fully-insured commercial plans.

If You Need More Information

Common Information Requests

Cigna may request additional documentation such as:

  • Updated laboratory values
  • Detailed transfusion logs
  • Specialist consultation notes
  • Treatment failure documentation for alternative therapies

Responding to Medical Necessity Questions

Address medical necessity concerns by providing:

  • FDA labeling information for Pyrukynd
  • Published clinical trial data
  • Hematology society treatment guidelines
  • Patient-specific clinical rationale

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient genetic confirmation Submit complete PKLR analysis Gene panel with ≥2 variants
Missing specialist prescription Obtain hematologist co-signature Board certification verification
Inadequate disease severity Provide comprehensive history Transfusion logs, hemoglobin trends
Missing concurrent therapy Document folic acid prescription Current medication list

Pennsylvania Appeals Process

  1. Request peer-to-peer review: Call Cigna at 1-800-88-CIGNA to speak directly with a medical director (80-85% success rate for appropriate cases)
  2. File internal appeal: Submit within 180 days to Cigna National Appeals Unit, including:
    • Copy of denial letter
    • Additional clinical evidence
    • Medical necessity letter from hematologist
  3. External review: After exhausting internal appeals, file with Pennsylvania Insurance Department within 4 months using their online portal at pa.gov
From our advocates: We've seen the strongest appeals include comprehensive genetic testing documentation paired with detailed transfusion histories. Patients who work closely with their hematologist to document treatment failures with supportive care often see faster approvals on appeal.

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned with each payer's requirements. For complex cases involving rare diseases like pyruvate kinase deficiency, their systematic approach to gathering the right clinical evidence and regulatory citations can significantly improve appeal success rates.

Renewal and Reauthorization

Annual Renewal Requirements

Cigna typically approves Pyrukynd for 12-month periods. For renewal, submit:

  • Updated hemoglobin levels showing improvement (≥1 g/dL increase)
  • Reduced transfusion requirements
  • Current laboratory panel (CBC, bilirubin, reticulocytes, LDH)
  • Hematologist assessment of treatment response and adherence

Timing Your Renewal

Start the renewal process 60 days before expiration. Obtain updated laboratory results 45 days prior to ensure current data is available for review.

Quick Reference Checklist

Before Submitting:

  • Genetic testing confirming ≥2 PKLR variants (≥1 missense)
  • Hemoglobin ≤10 g/dL OR ≥6 transfusions in 12 months
  • Hematologist prescription or consultation
  • Current folic acid supplementation documented
  • Complete laboratory panel (CBC, bilirubin, reticulocytes, LDH)
  • Transfusion history records

Submission:

  • Submit via Cigna provider portal (preferred) or fax
  • Request expedited review if urgent
  • Document reference number for tracking

Follow-Up:

  • Check status within 48 hours
  • Prepare for potential information requests
  • Calendar renewal 60 days before expiration

FAQ

How long does Cigna prior authorization take for Pyrukynd in Pennsylvania? Standard review takes 72 hours; expedited review for urgent cases takes 24 hours. Complex cases requiring additional documentation may take longer.

What if Pyrukynd is non-formulary on my Cigna plan? Submit a formulary exception request along with your prior authorization. Include medical necessity documentation explaining why alternative treatments are inappropriate.

Can I request an expedited appeal if denied? Yes, if you can demonstrate immediate health risk or urgent medical need. Provide clinical justification for expedited processing at each appeal level.

Does step therapy apply to Pyrukynd? Cigna may require documentation of supportive care measures (transfusions, folic acid) before approving Pyrukynd, but formal step therapy protocols vary by plan.

What if my employer has a self-funded Cigna plan? Self-funded plans may have different appeal processes and may not be eligible for Pennsylvania's external review program. Check your plan documents or contact HR for specific procedures.

How much does Pyrukynd cost without insurance? Wholesale acquisition cost is approximately $25,760 per carton (28-day supply). Patient assistance programs through Agios Pharmaceuticals may be available for eligible patients.

Sources & Further Reading

For additional support with complex prior authorization cases, Counterforce Health provides specialized assistance in developing evidence-backed appeals for specialty medications like Pyrukynd.

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact your insurance company or the Pennsylvania Insurance Department for plan-specific information and current policies.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.