By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (selpercatinib) Covered by Cigna in Ohio: Complete Prior Authorization and Appeal Guide

Answer Box: Fastest Path to Retevmo Coverage

Cigna requires prior authorization for Retevmo (selpercatinib) in Ohio. Your oncologist must submit documentation proving RET gene alteration via FDA-approved testing (like FoundationOne CDx), diagnosis of RET fusion-positive NSCLC or RET-mutant thyroid cancer, and prior treatment history. Submit through Cigna's provider portal with complete clinical records—decisions come within 72 hours. If denied, you have 180 days for internal appeal, then another 180 days for Ohio Department of Insurance external review. Start today: Ensure your RET testing results and treatment history are compiled for your oncologist's PA submission.

Table of Contents

Understanding Cigna's Retevmo Requirements

Retevmo (selpercatinib) is a targeted therapy for RET-altered cancers that costs approximately $23,000-$26,000 per month. Cigna manages this specialty drug through Express Scripts/Accredo pharmacy with strict prior authorization requirements.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Retevmo prescriptions Cigna provider portal Cigna PA Policy
RET Testing FDA-approved companion diagnostic confirming RET alteration FoundationOne CDx or Guardant360 CDx reports FDA Retevmo Label
Diagnosis RET fusion+ NSCLC or RET-mutant thyroid cancer Pathology reports, staging documents Cigna Coverage Criteria
Age Requirement 18 years or older Medical records Cigna PA Policy
Appeal Deadline 180 days for internal, 180 days for external Ohio insurance law Ohio DOI Appeals

Step-by-Step: Fastest Path to Approval

1. Confirm RET Testing Requirements

Who: Your oncologist
What: Order FDA-approved RET alteration testing if not already done
Options: FoundationOne CDx (tissue) or Guardant360 CDx (liquid biopsy)
Timeline: 7-14 days for results
Source: Retevmo HCP Testing Guide

2. Gather Clinical Documentation

Who: Medical team
What: Compile complete treatment history, staging, prior therapies
Include: Pathology reports, imaging, previous treatment outcomes
Timeline: 1-2 days

3. Submit Prior Authorization

Who: Prescribing oncologist only
How: Cigna provider portal or Express Scripts PA system
Timeline: Cigna decides within 72 hours (24-72 hours if expedited)
Source: Cigna PA Process

4. Monitor Decision

Who: Patient and clinic staff
What: Track PA status through provider portal
If approved: Proceed to specialty pharmacy fulfillment
If denied: Begin appeal process immediately

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing RET testing Submit FDA-approved test results FoundationOne CDx or Guardant360 CDx report showing specific RET alteration
Wrong tumor type Clarify diagnosis with staging Updated pathology confirming RET fusion+ NSCLC or RET-mutant thyroid cancer
Incomplete prior therapy history Document treatment sequence Detailed records of previous therapies, responses, and reasons for discontinuation
QT prolongation concerns Address cardiac monitoring plan Baseline ECG, electrolyte levels, cardiac monitoring protocol
From our advocates: We've seen denials overturned when oncologists include a detailed timeline showing how the patient progressed through standard therapies before needing Retevmo. The key is showing medical necessity through documented treatment failures, not just listing prior medications.

Appeals Playbook for Ohio

Internal Appeal (First Level)

  • Deadline: 180 days from denial date
  • Who files: Prescribing physician
  • Timeline: Cigna responds within 30 days (72 hours if expedited)
  • Submit to: Cigna via provider portal or written appeal
  • Required: Additional clinical documentation, updated medical necessity letter

External Review (Ohio Department of Insurance)

  • Deadline: 180 days from final internal denial
  • Who files: Patient or physician
  • Timeline: 30 days for decision (72 hours if expedited)
  • Submit to: Request through Cigna, forwarded to Ohio DOI
  • Outcome: Binding decision by independent medical experts
  • Contact: Ohio DOI Consumer Hotline: 1-800-686-1526
  • Source: Ohio External Review Process
Note: Ohio's external review process is particularly strong for specialty oncology drugs. The independent medical experts assigned to your case will have relevant expertise in RET-altered cancers.

Clinician Corner: Medical Necessity Letter

Essential Components Checklist

  • Diagnosis: Specific cancer type with staging (e.g., "Stage IV RET fusion-positive NSCLC")
  • RET Testing: Include specific alteration found (e.g., "CCDC6-RET fusion detected by FoundationOne CDx")
  • Prior Therapies: Detailed sequence with outcomes and reasons for discontinuation
  • Treatment Goals: Disease control, symptom management, quality of life
  • Contraindications: Why alternatives aren't suitable
  • Monitoring Plan: QT monitoring, drug interaction management
  • Guideline Support: Reference NCCN guidelines for RET-targeted therapy

Key Talking Points for Peer-to-Peer Review

When Cigna requests a peer-to-peer discussion:

QT Prolongation Management:

  • "We'll monitor QTc at baseline, week 1, monthly for 6 months, then as clinically indicated"
  • "Grade 3 QT prolongation (>500ms) protocol: hold drug, resume at lower dose when <470ms"
  • "Only 0.1% of patients experience serious cardiac events in clinical trials"

Drug Interactions:

  • "We've reviewed all concomitant medications and will avoid strong CYP3A inhibitors"
  • "Patient education includes reporting any new medications or cardiac symptoms"

Source: Selpercatinib Safety Profile

Cost-Saving Options

Manufacturer Support

  • Lilly Cares Foundation: Income-based assistance for eligible patients
  • Retevmo Savings Program: May reduce copays for commercially insured patients
  • Contact: Visit manufacturer website to verify current programs

State Resources

  • Ohio Patient Advocate Foundation: Provides case management for insurance appeals
  • UHCAN Ohio: Consumer health advocacy organization
Tip: Apply for manufacturer assistance programs while your prior authorization is pending—approval can take several weeks.

FAQ

Q: How long does Cigna prior authorization take for Retevmo in Ohio? A: Standard decisions within 72 hours; expedited reviews in 24-72 hours if your doctor justifies urgency due to disease progression.

Q: What if Retevmo isn't on Cigna's formulary? A: Your doctor can request a formulary exception with medical necessity documentation. Ohio law requires insurers to have an exception process.

Q: Can I get an expedited appeal if my cancer is progressing? A: Yes. Your oncologist must document that delays would seriously jeopardize your health. Expedited appeals get decisions within 72 hours.

Q: What happens if both internal appeals are denied? A: You can request external review through the Ohio Department of Insurance within 180 days. This involves independent medical experts and is binding on Cigna.

Q: Does step therapy apply to Retevmo? A: Cigna may require documentation of prior therapy failures, but RET-targeted therapy is often considered first-line for RET-positive cancers per NCCN guidelines.

When to Escalate

Contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526 if:

  • Cigna misses appeal deadlines
  • You're told you're not eligible for external review (Ohio DOI can override this)
  • The insurer requests unreasonable documentation
  • You need help understanding your appeal rights

For complex cases, consider consulting with Counterforce Health, which specializes in turning insurance denials into targeted, evidence-backed appeals for prescription drugs. Their platform helps identify denial reasons and drafts point-by-point rebuttals aligned to payer policies.

Checklist: What to Gather Before Starting

  • Insurance card with member ID
  • Complete RET testing results (FoundationOne CDx or equivalent)
  • Pathology reports confirming cancer diagnosis and staging
  • Complete treatment history with dates, responses, and discontinuation reasons
  • Current lab values and imaging studies
  • Any previous denial letters or explanations of benefits (EOBs)
  • Prescriber contact information and office notes

Timeline Overview

Step Timeframe Action Required
RET Testing 7-14 days Order if not completed
PA Submission Same day Oncologist submits complete packet
Initial Decision 72 hours Cigna approval/denial
Internal Appeal 30 days File within 180 days of denial
External Review 30 days File within 180 days of final internal denial

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and healthcare provider.

Sources & Further Reading

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