By Counterforce Health Team in Soliris (eculizumab) —

How to Get Soliris (Eculizumab) Covered by Cigna in New York: Complete Timeline and Appeal Guide

Answer Box: Getting Soliris Covered by Cigna in New York

Getting Soliris (eculizumab) covered by Cigna in New York requires prior authorization with a 5-day standard review timeline. The fastest path: (1) Complete Cigna's Soliris PA form with all required documentation—FDA-approved diagnosis, meningococcal vaccination records, and REMS enrollment proof, (2) Submit via Cigna's online portal or call 800-882-4462 for urgent cases, (3) If denied, file an internal appeal within 180 days, then escalate to New York's external review system through the Department of Financial Services within 4 months. Start today by downloading Cigna's Soliris PA form and gathering your vaccination records.

Table of Contents

  1. What Affects Soliris Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window and Outcomes
  6. If Denied: New York Appeal Timeline
  7. Renewal Cycles and Maintenance
  8. Timeline Visual: Milestones
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. Appeals Playbook for New York
  12. Cost-Saving Options
  13. FAQ

What Affects Soliris Approval Timing

Several factors influence how quickly Cigna approves Soliris (eculizumab) in New York:

Benefit Type: Soliris is typically managed through Express Scripts/Accredo as a specialty drug, requiring specialized handling that can add 1-2 days to processing compared to standard medications.

Complexity of Criteria: Soliris has strict FDA indications—paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS), generalized myasthenia gravis (gMG), and neuromyelitis optica spectrum disorder (NMOSD). Each requires specific diagnostic documentation and laboratory evidence.

Documentation Completeness: The most common cause of delays is incomplete submission. Missing meningococcal vaccination records, absent REMS enrollment proof, or insufficient diagnostic workup can extend the review by 5-10 business days.

Note: Cigna's standard review timeline is 5 business days in New York, but urgent requests can be expedited to 24-72 hours with proper medical justification.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your prior authorization request, gather these required documents:

Clinical Documentation:

  • Confirmed FDA-approved diagnosis with supporting lab results
  • For PNH: Flow cytometry results showing CD55/CD59-deficient cells
  • For aHUS: Evidence excluding STEC-HUS and TTP
  • For gMG: Anti-AChR antibody positivity documentation
  • For NMOSD: AQP4 antibody test results

Safety Requirements:

  • Meningococcal vaccination records (both MenACWY and MenB series)
  • Vaccination must be completed ≥2 weeks before first dose
  • If urgent therapy needed, antibiotic prophylaxis prescription required

REMS Program:

  • Prescriber enrollment confirmation in Soliris REMS program
  • Patient counseling documentation
  • Patient Safety Card acknowledgment

Verification Steps

  1. Confirm Insurance Coverage: Call Cigna member services at 1-800-244-6224 to verify active coverage and specialty drug benefits
  2. Check Formulary Status: Review Cigna's current formulary to confirm Soliris coverage tier
  3. Gather Provider Information: Ensure prescribing physician is credentialed with Cigna and specializes in relevant condition

Submission to Initial Review (1-5 Days)

How to Submit

Online Portal (Fastest): Submit through Cigna's provider portal or CoverMyMeds platform Phone (Urgent Cases): Call 800-882-4462 for expedited review requests Fax: Submit completed forms to Cigna's specialty pharmacy fax line (verify current number with Cigna)

What Reviewers Check First

Cigna's initial review focuses on:

  1. FDA Indication Match: Does the diagnosis align with approved uses?
  2. Safety Compliance: Are vaccination requirements met?
  3. Prior Authorization Form Completeness: All required fields completed?
  4. Provider Credentials: Is the prescriber appropriately specialized?

New York State Requirements: Under New York insurance law, Cigna must acknowledge receipt within 1 business day and provide a determination within the standard timeframe unless additional information is needed.

Additional Information Requests (1-7 Days)

If Cigna requests additional information, you'll receive notification within 2-3 days of initial submission. Common requests include:

Medical Records: Complete chart notes from specialist visits Laboratory Results: Recent lab work supporting diagnosis Prior Therapy Documentation: Records of previous treatments and outcomes Vaccination Updates: More recent vaccination records if initial ones are outdated

How to Respond Quickly

  • Same-Day Response: Submit additional documents through the same portal used for initial request
  • Include Reference Numbers: Always reference the original PA request number
  • Direct Communication: Have your provider call Cigna directly at the number provided in the request letter
Tip: Incomplete responses restart the review clock, so ensure all requested information is provided in a single submission.

Decision Window and Outcomes

Typical Timeline

  • Standard Review: 5 business days from complete submission
  • Expedited Review: 24-72 hours for urgent medical situations
  • Additional Information: Clock pauses until complete response received

Reading Your Approval Letter

Approved: Letter will specify covered quantity, duration, and any special requirements Denied: Letter must include specific reason for denial and appeal rights information Pending: Request for additional information with specific requirements listed

If Denied: New York Appeal Timeline

New York residents have robust appeal rights when Cigna denies Soliris coverage:

Internal Appeals (Required First Step)

  • Deadline: 180 days from denial notice
  • Timeline: Cigna has 15 days for standard appeals, 72 hours for expedited
  • How to File: Submit written appeal with supporting documentation

External Review (New York State)

  • Deadline: 4 months after final internal denial
  • Authority: New York Department of Financial Services (DFS)
  • Timeline: 30 days for standard, 72 hours for expedited cases
  • Success Rate: 38-55% of specialty drug appeals are overturned
  • Cost: $25 (waived for Medicaid/financial hardship)

File External Appeal: Submit through DFS online portal or mail forms to New York Department of Financial Services.

Renewal Cycles and Maintenance

Soliris typically requires reauthorization every 6-12 months. Factors affecting renewal timing:

Stable Patients: Annual renewal with updated labs and clinical notes Changing Conditions: More frequent reviews (6 months) if disease progression noted New Formulations: If switching to biosimilar versions (Bkemv, Epysqli), new PA required

Renewal Acceleration Tips

  • Submit renewal requests 30 days before expiration
  • Include updated efficacy data and safety monitoring results
  • Maintain consistent specialist care documentation

Timeline Visual: Milestones

Phase Timeline Key Actions Expected Outcome
Preparation 0-2 days Gather documents, verify coverage Complete submission ready
Initial Submission Day 1 Submit PA form with all documentation Receipt acknowledgment
Under Review Days 2-5 Cigna clinical review process Determination or info request
Additional Info Days 6-12 Respond to any requests Complete review resumes
Decision Days 5-15 Final determination issued Approval, denial, or partial approval
Appeal (if needed) Days 16-195 Internal appeal process Overturn or uphold denial
External Review Days 196-226 New York DFS review Final binding decision

Time-Saving Tips

Use Digital Portals: Online submissions process 2-3 days faster than fax Bundle Evidence: Submit all supporting documents in single package Specialty Pharmacy Coordination: Work directly with Accredo or designated specialty pharmacy Provider Communication: Ensure prescriber is available for peer-to-peer review if requested

Counterforce Health Support: For complex appeals, consider using Counterforce Health, which helps patients turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to plan policies.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient diagnostic evidence Submit complete lab workup Flow cytometry, antibody tests, specialist consultation notes
Missing vaccination records Provide meningococcal vaccine documentation Vaccination cards, pharmacy records, provider attestation
REMS non-compliance Complete enrollment process REMS enrollment confirmation, patient counseling documentation
Step therapy requirement Document prior therapy failures Treatment history, intolerance documentation, clinical rationale
Non-formulary status Request formulary exception Medical necessity letter, lack of alternatives documentation

Appeals Playbook for New York

Level 1: Internal Appeal

Deadline: 180 days from denial Process: Submit written appeal to Cigna with medical records Timeline: 15 days (standard), 72 hours (expedited)

Level 2: External Review

Authority: New York Department of Financial Services Deadline: 4 months after final internal denial Process: Submit DFS external appeal form with complete medical record Timeline: 30 days (standard), 72 hours (urgent)

Escalation Resources

Community Health Advocates: Free appeal assistance at (888) 614-5400 New York DFS Consumer Helpline: File complaints about insurer delays or violations

Cost-Saving Options

Manufacturer Support:

  • Alexion OneSource: Financial assistance and copay support
  • Patient assistance programs for uninsured/underinsured

Foundation Grants:

  • HealthWell Foundation: Rare disease assistance
  • National Organization for Rare Disorders (NORD): Patient assistance programs

State Programs:

  • New York State of Health: Premium tax credits and cost-sharing reductions
  • Medicaid: Comprehensive coverage for eligible individuals

FAQ

How long does Cigna PA take in New York? Standard review is 5 business days; expedited review is 24-72 hours for urgent cases.

What if Soliris is non-formulary on my plan? Request a formulary exception with medical necessity documentation. New York law requires insurers to have exception processes.

Can I request an expedited appeal? Yes, if delay could seriously jeopardize your health. Both internal and external appeals have expedited pathways.

Does step therapy apply if I've failed therapies outside New York? Documentation from any licensed provider is acceptable. Provide complete treatment history and outcomes.

What happens if my external appeal is denied? DFS external review decisions are final and binding. Consider consulting with legal advocacy organizations for next steps.

How much does Soliris cost without insurance? Annual costs can reach $500,000+. Never attempt to pay out-of-pocket without exploring all coverage and assistance options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for the most current requirements and procedures. Insurance policies and state regulations may change. For personalized assistance with your specific situation, contact the resources listed above or consult with a qualified healthcare advocate.

Need Expert Help? Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed rebuttals tailored to each payer's specific policies and requirements. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes more effectively.

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