By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Cigna in Texas: Appeals, Copay Cards & Cost Solutions

Quick Answer: Getting Retevmo (Selpercatinib) Covered by Cigna in Texas

Retevmo requires prior authorization from Cigna and is typically placed on a high specialty tier (4 or 5) with significant out-of-pocket costs. Your fastest path to approval: 1) Ensure you have genetic testing confirming RET fusion/mutation, 2) Have your oncologist submit a detailed PA request with diagnosis codes and prior therapy documentation, and 3) If denied, file an internal appeal within 180 days. Eligible patients with commercial insurance can use Eli Lilly's copay card to pay as little as $0 per month (up to $25,000 annually). Start by calling Cigna member services to verify your exact formulary tier and PA requirements.

Table of Contents

Understanding Retevmo's Cost Drivers

Retevmo (selpercatinib) is an oral targeted therapy for RET fusion-positive non-small cell lung cancer and RET-mutant thyroid cancers. At roughly $23,000-$26,000 per month without insurance, understanding your coverage is crucial.

Why Retevmo Costs So Much Through Insurance:

  • Specialty tier placement: Cigna typically places Retevmo on Tier 4 or 5, meaning 20-50% coinsurance rather than flat copays
  • Prior authorization required: All requests need clinical review and approval
  • Specialty pharmacy mandate: Must be filled through designated specialty pharmacies like Accredo
  • Quantity limits: Usually restricted to 30-day supplies with refill monitoring
Note: Even with insurance approval, your monthly out-of-pocket could range from hundreds to thousands of dollars depending on your specific plan design.

Investigating Your Cigna Benefits

Before starting the approval process, gather this critical information by calling Cigna member services or logging into your online portal:

Essential Questions to Ask:

  1. "Is Retevmo on my formulary, and what tier?"
  2. "What's my specialty drug coinsurance percentage?"
  3. "Do I have an annual out-of-pocket maximum for specialty drugs?"
  4. "Is prior authorization required, and who handles it—Cigna or Express Scripts?"
  5. "Which specialty pharmacies are in-network for Retevmo?"

Information to Record:

  • Your exact plan name and member ID
  • Specialty drug benefit details (deductible, coinsurance, out-of-pocket max)
  • Prior authorization phone number and fax
  • Preferred specialty pharmacy contact information

Assistance Options: Copay Cards and Grants

Manufacturer Support

Eli Lilly Retevmo Savings Card is your first line of defense against high costs:

  • Eligible patients pay as little as $0 for a 30-day supply
  • Maximum annual savings: $25,000 per patient
  • Eligibility: Commercial insurance only (excludes Medicare, Medicaid, VA, Tricare)
  • How to enroll: Call 1-800-545-5979 or visit retevmo.lilly.com/savings-support

Foundation Grants

If you don't qualify for manufacturer assistance or need additional support:

From our advocates: We've seen patients combine manufacturer copay cards with foundation grants to virtually eliminate out-of-pocket costs for the first year of treatment. The key is applying early—many foundation programs have limited funding that runs out quickly.

Getting Prior Authorization Approved

Cigna requires prior authorization for Retevmo, and approval hinges on meeting specific medical criteria.

Required Documentation

Your oncologist must provide:

Clinical Evidence:

  • Pathology report confirming RET fusion-positive NSCLC or RET-mutant thyroid cancer
  • FDA-approved or validated genetic test results (not just any molecular test)
  • Current staging and performance status
  • Documentation of appropriate patient selection per FDA labeling

Prior Treatment History:

  • Details of previous therapies tried and failed (if applicable)
  • Reasons for discontinuation (progression, intolerance, contraindications)
  • Response to prior treatments with dates and imaging

Safety Considerations:

  • Recent ECG showing QTc interval (Retevmo can prolong QT)
  • Liver function tests (baseline ALT, AST, bilirubin)
  • Current medications to assess drug interactions

Step-by-Step: Fastest Path to Approval

  1. Genetic Testing Confirmation (Patient/Oncologist)
    • Ensure RET testing used FDA-approved/validated assay
    • Obtain written report with specific fusion or mutation details
    • Timeline: Results typically available within 1-2 weeks
  2. Prior Authorization Submission (Oncologist's office)
    • Complete Cigna PA form with all required clinical documentation
    • Submit via Cigna provider portal or fax to number on PA form
    • Timeline: Standard review within 72 hours
  3. Peer-to-Peer Review (If initially denied)
    • Request physician-to-physician discussion with Cigna medical director
    • Schedule within 24-48 hours of denial notification
    • Timeline: Usually resolved within 1-2 business days

When Cigna Says No: The Appeals Process

If Cigna denies your Retevmo request, Texas law provides strong appeal rights with specific timelines.

Internal Appeals in Texas

Filing Deadline: 180 calendar days from denial notice

Review Timeline:

How to File:

  • Call Cigna member services to initiate
  • Submit written appeal with supporting documentation
  • Request expedited review if treatment delay poses health risks

External Review Rights

If Cigna upholds the denial after internal appeal, Texas provides independent external review through contracted Independent Review Organizations (IROs).

Key Benefits:

  • Impartial medical review by specialists not employed by Cigna
  • IRO decision is binding on the insurance company
  • Standard timeline: 20 days; expedited: 5 days for urgent cases
  • Cost covered by Cigna, not you

How to Access: Texas Department of Insurance provides guidance at 1-800-252-3439 or through their consumer help website.

Specialty Pharmacy Coordination

Retevmo must be dispensed through specialty pharmacies, which requires coordination between your oncologist, Cigna, and the pharmacy.

Cigna's Preferred Specialty Pharmacies:

  • Accredo (Express Scripts specialty arm)
  • CVS Specialty
  • Walgreens Specialty Pharmacy

Coordination Tips:

  • Confirm your preferred pharmacy is in-network before PA submission
  • Provide pharmacy with your copay card information before first fill
  • Set up automatic refills to avoid treatment interruptions
  • Ask about 90-day supplies if your plan allows (may reduce copays)

Counterforce Health helps patients navigate these complex specialty pharmacy requirements by turning insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters and plan policies to draft point-by-point rebuttals aligned to your specific payer's rules.

Annual Renewal Planning

Your Retevmo coverage can change each year during your plan's open enrollment period.

What Can Change:

  • Formulary tier placement (potentially moving to higher cost-sharing tier)
  • Prior authorization requirements (new criteria or documentation needs)
  • Preferred specialty pharmacy networks
  • Copay assistance program terms

Renewal Checklist (Complete each October-November):

  • Review next year's formulary for Retevmo placement
  • Confirm specialty pharmacy remains in-network
  • Re-enroll in Eli Lilly copay assistance program (12-month terms)
  • Update any changed contact or insurance information with your specialty pharmacy

Scripts for Key Conversations

Calling Cigna Member Services

"Hi, I'm calling about prior authorization requirements for Retevmo, spelled R-E-T-E-V-M-O, also known as selpercatinib. My member ID is [number]. I need to know: Is this drug on my formulary? What tier is it on? What's my coinsurance for specialty tier drugs? And what documentation does my doctor need to submit for prior authorization?"

Requesting Expedited Appeal

"I'm requesting an expedited appeal for my Retevmo denial. My oncologist can provide documentation that any delay in starting this targeted therapy could seriously jeopardize my health given my cancer diagnosis. When can we schedule a peer-to-peer review with your medical director?"

Specialty Pharmacy Coordination

"I have a new Retevmo prescription that needs prior authorization. I also have an Eli Lilly copay card that should reduce my out-of-pocket to $0. Can you coordinate the PA with Cigna and apply my copay assistance before processing the first fill?"

FAQ

How long does Cigna prior authorization take for Retevmo in Texas? Standard PA decisions are made within 72 hours, though complex cases may take longer. Expedited reviews are completed within 24 hours when medical urgency is documented.

What if Retevmo isn't on my Cigna formulary? You can request a formulary exception within 72 hours by having your physician document medical necessity and why formulary alternatives aren't appropriate for your specific RET-positive cancer.

Can I use manufacturer copay assistance with Medicare? No, federal anti-kickback laws prohibit manufacturer copay cards for Medicare, Medicaid, VA, and other government insurance beneficiaries. However, foundation grants may be available.

What counts as medical necessity for Retevmo? Medical necessity requires FDA-approved indication (RET fusion-positive NSCLC or RET-mutant thyroid cancer), confirmed by validated genetic testing, with appropriate patient selection per prescribing information.

How do I file a complaint if Cigna wrongly denies my appeal? Contact the Texas Department of Insurance consumer help line at 1-800-252-3439 or file a complaint online. For Medicare plans, contact Medicare at 1-800-MEDICARE.

Does step therapy apply if I haven't tried other treatments? Step therapy requirements vary by plan. For RET-positive cancers, Retevmo may be first-line therapy per FDA labeling, potentially bypassing step therapy requirements with proper documentation.

This article provides educational information only and is not medical or legal advice. Coverage decisions depend on your specific insurance plan and medical circumstances. For personalized guidance, consult your healthcare team and insurance plan documents.

Texas Resources:

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements for targeted therapies like Retevmo.

Sources & Further Reading

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