By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Cigna in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Retevmo (Selpercatinib) Covered by Cigna in Washington

Cigna requires prior authorization for Retevmo (selpercatinib) for RET fusion-positive NSCLC and RET-altered thyroid cancers. Key requirements: FDA-approved RET test results, advanced/metastatic disease documentation, and NCCN-aligned medical necessity. If denied, Washington residents can use internal appeals (180-day deadline) followed by Independent Review Organization (IRO) external review through the Office of Insurance Commissioner. First step today: Have your oncologist gather RET test results and submit PA via Cigna's provider portal with complete clinical documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Retevmo prescriptions Cigna provider portal or PA form Cigna PA Policy
RET Testing FDA-approved test confirming RET fusion/mutation Pathology report from CLIA lab FDA Companion Diagnostics
Disease Status Advanced, metastatic, or recurrent cancer Staging reports, imaging studies NCCN Guidelines
Specialty Pharmacy Dispensed through Express Scripts/Accredo Cigna specialty pharmacy network Express Scripts Specialty
Appeals Deadline 180 days from denial for internal appeal Denial letter instructions Washington RCW 48.43.535

Step-by-Step: Fastest Path to Approval

1. Confirm RET Status with FDA-Approved Testing

Who: Oncologist orders test
Document needed: Comprehensive genomic profiling (FoundationOne CDx, Guardant360 CDx)
Timeline: 7-14 days for results
Key point: Cigna requires specific RET fusion (NSCLC/thyroid cancer) or RET mutation (medullary thyroid cancer) documentation

2. Gather Complete Clinical Documentation

Who: Clinic staff assembles packet
Documents needed:

  • Pathology reports confirming cancer type and stage
  • RET test results with specific alteration identified
  • Prior treatment history with dates and outcomes
  • Current imaging showing disease status
  • ECOG performance status note

3. Submit Prior Authorization

Who: Prescriber submits via CignaForHCP portal
Timeline: 72 hours standard review, 24-72 hours expedited
Required elements:

  • FDA indication match (RET fusion-positive NSCLC, RET-mutant MTC, RET fusion-positive DTC)
  • NCCN guideline alignment citation
  • Medical necessity justification

4. Request Peer-to-Peer if Initially Denied

Who: Oncologist calls Cigna medical director
Timeline: Within 24-48 hours of denial
Talking points: Policy compliance, NCCN preferred status, inadequacy of alternatives

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing RET documentation Submit complete pathology report FDA-approved test results with specific RET alteration
"Not medically necessary" Cite NCCN preferred status NCCN guidelines excerpt, FDA label
Step therapy required Document contraindications to alternatives Prior therapy failures, toxicity reports
Insufficient disease staging Provide imaging evidence CT/PET scans showing metastatic disease
QT prolongation concerns Include monitoring plan Baseline EKG, cardiology clearance

Appeals Process in Washington

Internal Appeals with Cigna

Deadline: 180 days from denial notice
How to file: Written appeal via Cigna member portal or mail
Timeline: 30 days for standard review, 72 hours for expedited cancer cases
Required documents:

  • Original denial letter
  • Complete medical records
  • Updated physician letter addressing denial reasons
  • Supporting literature (NCCN, clinical studies)

External Review (IRO Process)

If Cigna upholds the denial after internal appeals, Washington residents can request Independent Review Organization (IRO) external review under RCW 48.43.535.

Key features:

  • Deadline: 4 months from original denial or 180 days from final internal denial
  • Process: Request through Cigna, who assigns IRO via Washington Office of Insurance Commissioner
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patient; Cigna pays IRO fees
  • Decision: Binding on Cigna if IRO overturns denial

How it works:

  1. Submit external review request to Cigna using their form
  2. Cigna forwards case to IRO within 3 business days
  3. You have 5+ business days to submit additional evidence directly to IRO
  4. IRO panel reviews all evidence and makes binding decision

Medical Necessity Letter Checklist

Essential Elements for Oncologist's Letter

Patient Information:

  • Diagnosis with ICD-10 codes (C34.x for NSCLC, C73 for thyroid cancer)
  • Disease stage and metastatic sites
  • ECOG performance status

RET Testing Documentation:

  • Specific RET alteration (e.g., KIF5B-RET fusion, RET M918T mutation)
  • Testing methodology (NGS, FISH, RT-PCR)
  • Laboratory and report date

Treatment History:

  • Prior systemic therapies with start/stop dates
  • Reasons for discontinuation (progression, toxicity, intolerance)
  • Response assessment (RECIST criteria where applicable)

Medical Necessity Justification:

  • FDA approval for specific indication
  • NCCN Drugs & Biologics Compendium preferred status
  • Superior efficacy vs. non-targeted alternatives
  • Consequences of treatment delay

Safety Monitoring Plan:

  • Baseline assessments (EKG, LFTs, blood pressure)
  • Drug interaction review
  • Monitoring schedule per FDA label
Tip: Reference specific sections of Cigna's Retevmo policy to demonstrate compliance with their stated criteria.

Costs & Patient Assistance

Retevmo Pricing and Support Options

Cash price: $23,000-$26,000 per 30-day supply
Cigna coverage: Typically specialty tier with 20-40% coinsurance

Patient Assistance Programs:

  • Lilly Cares Foundation: Income-based free drug program
  • Retevmo Copay Card: Up to $25,000/year in copay assistance for commercially insured patients
  • Washington State programs: Apple Health (Medicaid expansion) may cover with prior authorization

Financial navigation: Counterforce Health helps patients navigate insurance denials and appeals for specialty oncology drugs like Retevmo, turning denials into targeted, evidence-backed appeals that align with payer policies.

From Our Advocates

"We've seen Retevmo approvals succeed when oncologists clearly document the specific RET alteration and cite NCCN preferred status in the initial PA request. The key is matching Cigna's exact policy language while emphasizing that selective RET inhibition is now standard of care for RET-driven cancers. This approach has helped many patients avoid lengthy appeals processes."

When to Contact Washington Regulators

Office of Insurance Commissioner (OIC)

Consumer Advocacy Hotline: 1-800-562-6900
When to call:

  • Cigna misses appeal deadlines
  • Questions about IRO external review process
  • Suspected improper denial practices
  • Need help understanding your rights

What OIC can do:

  • Explain Washington insurance laws
  • Ensure proper IRO assignment
  • Investigate pattern of improper denials
  • Provide template appeal letters

File a complaint: Washington OIC website if Cigna violates state insurance regulations.

FAQ

How long does Cigna prior authorization take for Retevmo in Washington?
Standard review is 72 hours; expedited review for urgent cases is 24-72 hours. Cigna must notify you of the decision within these timeframes per their policy.

What if Retevmo is non-formulary on my Cigna plan?
You can request a formulary exception with medical necessity documentation. Emphasize FDA approval and NCCN preferred status for your specific RET-positive cancer.

Can I request an expedited appeal if Retevmo is denied?
Yes, if delay would seriously jeopardize your health. Have your oncologist document urgency and request expedited review (72-hour timeline for internal appeals).

Does Washington's external review apply to all Cigna plans?
It applies to state-regulated (fully insured) plans. Large employer self-funded plans may follow federal ERISA rules instead, but many voluntarily use IRO processes.

What happens if the IRO overturns Cigna's denial?
Cigna must provide coverage as directed by the IRO. The decision is legally binding on the insurer under Washington law.

How much does external review cost in Washington?
External review is free to patients. Cigna pays all IRO fees regardless of the outcome.

Can I submit additional evidence during the IRO review?
Yes, you have at least 5 business days to submit additional information directly to the IRO after they're assigned to your case.

What if I need help with the appeals process?
Contact the Washington Office of Insurance Commissioner at 1-800-562-6900. They provide free consumer advocacy and can guide you through the process.

Understanding your rights and following these systematic steps significantly improves your chances of getting Retevmo covered by Cigna in Washington. The combination of strong initial documentation, strategic appeals, and Washington's robust external review process provides multiple pathways to access this life-changing medication.

For complex cases involving multiple denials or unusual circumstances, organizations like Counterforce Health specialize in transforming insurance denials into successful appeals by leveraging payer-specific policies and clinical evidence.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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