By Counterforce Health Team in Strensiq (asfotase alfa) —

How to Get Strensiq (asfotase alfa) Covered by Cigna in Georgia: Complete Guide to Prior Authorization, Appeals, and Urgent Access

Quick Answer: Your Path to Strensiq Coverage in Georgia

Cigna covers Strensiq (asfotase alfa) for pediatric-onset hypophosphatasia when you meet specific criteria. Your fastest path: (1) Ensure you have documented pediatric-onset HPP with ALPL mutation and low ALP levels, (2) Have your specialist submit an urgent prior authorization through Cigna's portal with complete diagnostic evidence, and (3) Enroll simultaneously with Alexion OneSource for support. Start today: Call your endocrinologist or geneticist to schedule an appointment and gather your childhood medical records showing early HPP symptoms.

Table of Contents

Is Strensiq Covered by Cigna?

Yes, Cigna covers Strensiq under their enzyme replacement therapy policy for patients with perinatal/infantile-onset and juvenile-onset hypophosphatasia (HPP). Coverage is not available for adult-onset HPP unless you can document that symptoms began before age 18.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all use Cigna PA Policy
Formulary Status Specialty tier with coinsurance Your plan documents
Age Restriction Pediatric-onset only (symptoms <18 years) Cigna Policy IP0308
Specialist Required Endocrinologist, geneticist, or metabolic specialist Coverage criteria
Renewal Annual reauthorization Policy guidelines

Prior Authorization Process

Who Submits the Prior Authorization

Your prescribing specialist (endocrinologist, geneticist, or metabolic disease expert) must submit the PA through Cigna's provider portal. You cannot submit this yourself.

Required Documentation

Your specialist must provide:

  1. Confirmed HPP diagnosis with pediatric-onset evidence
  2. ALPL genetic testing showing pathogenic variants
  3. Laboratory results: Low serum alkaline phosphatase (ALP) for age/sex
  4. Elevated substrate levels (PLP, PPi, or PEA when available)
  5. Radiographic evidence of HPP-related skeletal disease
  6. Clinical manifestations consistent with pediatric-onset HPP
  7. Dosing justification within FDA-approved limits (6-9 mg/kg/week)
Tip: Ask your specialist to reference Cigna's specific policy criteria (IP0308) in their submission to align with their requirements exactly.

Timing and Urgent Access

Standard Timeline

  • Routine PA: 3-7 business days for complete submissions
  • Incomplete requests: May take 2-3 weeks with back-and-forth

Expedited/Urgent Process

When HPP symptoms pose immediate risk (respiratory compromise, severe pain, fracture risk), your doctor can request urgent review:

  • Urgent PA timeline: 24-72 hours
  • Requirements: Clear documentation of why delay would cause serious harm
  • How to request: Mark as "urgent/expedited" in Cigna portal submission

If you need urgent access:

  1. Ask your specialist to submit as urgent PA with detailed severity documentation
  2. Call Cigna member services within 24 hours to confirm urgent status
  3. Enroll with Alexion OneSource same day for additional support

Eligibility Criteria

Cigna's Specific Requirements

Based on Cigna's enzyme replacement therapy policy, you must have:

Diagnostic Confirmation:

  • Pathogenic ALPL gene variants, OR
  • Low baseline serum ALP activity, OR
  • Elevated TNSALP substrates (PLP, PPi, PEA)

Clinical Evidence:

  • Perinatal/infantile symptoms: Respiratory compromise, poor growth, craniosynostosis, seizures
  • Juvenile symptoms: Fractures, delayed walking, premature tooth loss, skeletal deformities

Prescriber Requirements:

  • Must be prescribed by or in consultation with a geneticist, endocrinologist, or metabolic specialist

Common Denial Reasons and Solutions

Denial Reason How to Address
"Adult-onset HPP" Provide childhood medical records, dental records showing premature tooth loss, family history
"Insufficient documentation" Submit complete genetic testing, age-adjusted ALP levels, imaging studies
"Not medically necessary" Include specialist letter citing FDA approval, lack of alternatives, functional impact
"Experimental/investigational" Reference FDA approval (2015) and published efficacy data

Cost and Financial Assistance

Insurance Cost-Sharing

Strensiq is typically placed on Cigna's specialty tier with:

  • Commercial plans: 20-50% coinsurance
  • Medicare plans: 25% coinsurance in initial coverage phase
Important: Given Strensiq's high cost (potentially hundreds of thousands annually), even modest coinsurance percentages can result in substantial out-of-pocket expenses.

Financial Assistance Options

  1. Alexion OneSource Patient Support
    • Commercial copay assistance (up to annual maximums)
    • Free drug programs for qualifying uninsured patients
    • Enroll at alexiononesource.com
  2. Independent Charitable Foundations
    • Available for Medicare patients (manufacturer copay cards not allowed)
    • OneSource can help connect you with appropriate foundations
  3. Cigna Copay Accumulator Programs
    • Ask specifically if your plan uses accumulator or maximizer programs
    • These affect whether manufacturer assistance counts toward your deductible

Denials and Appeals in Georgia

Internal Appeals with Cigna

Timeline: 180 days from denial letter to file first-level appeal

How to Submit:

  1. Follow instructions in your denial letter
  2. Include point-by-point rebuttal addressing each denial reason
  3. Attach complete medical records, genetic testing, specialist letters
  4. Request peer-to-peer review between your specialist and Cigna medical director

Georgia External Review Process

After internal appeals are exhausted, Georgia residents have the right to independent external review through the Georgia Department of Insurance.

Key Details:

  • Filing deadline: 60 days from final internal denial
  • Cost: Free to patients
  • Timeline: 30 business days for standard review; 72 hours for expedited
  • Decision: Binding on Cigna if favorable

To Request External Review:

  1. Submit application to GA Office of Commissioner of Insurance and Fire Safety
  2. Call Consumer Services at 1-800-656-2298 for assistance
  3. Include all medical documentation and internal appeal correspondence
Georgia Advantage: The state's external review process has successfully overturned wrongful denials for specialty medications when comprehensive evidence is provided.

Specialty Pharmacy Process

Accredo Enrollment

Most Cigna plans use Accredo as their specialty pharmacy for Strensiq.

After PA Approval:

  1. Cigna routes prescription information to Accredo
  2. Accredo contacts you for profile setup and shipping details
  3. First order typically ships within 1-3 business days
  4. Track orders through myCigna app

For Urgent Processing:

  • Call Accredo directly after PA approval
  • Request expedited processing due to medical urgency
  • Confirm shipping address and any special handling needs

Troubleshooting Common Issues

Missing or Delayed Documentation

  • Problem: PA delayed due to incomplete genetic testing
  • Solution: Ask your specialist to submit available evidence while genetic results are pending; update submission when results available

Portal or System Issues

  • Problem: Provider portal down or not accepting submissions
  • Solution: Have your doctor's office call Cigna provider services for alternative submission methods

Coordination Between OneSource and Cigna

  • Problem: Disconnect between manufacturer support and insurance approval
  • Solution: Provide OneSource with your PA reference number and ask them to coordinate directly with Cigna

FAQ

How long does Cigna prior authorization take for Strensiq in Georgia? Standard PA: 3-7 business days. Urgent PA: 24-72 hours when properly documented as medically urgent.

What if Strensiq is non-formulary on my plan? Submit a formulary exception request along with the PA, emphasizing medical necessity and lack of alternatives.

Can I get expedited appeals in Georgia? Yes, both Cigna internal appeals and Georgia external review offer expedited processes for urgent medical situations.

Does step therapy apply to Strensiq? Typically no, since Strensiq is the only FDA-approved disease-modifying therapy for HPP. However, plans may require documentation of supportive care attempts.

What happens if I move from another state to Georgia? Your Cigna coverage should continue, but confirm your specialist network and specialty pharmacy access remain the same.

How often do I need reauthorization? Annual reauthorization is typically required, with documentation of continued medical necessity and treatment response.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients seeking access to prescription medications. Our platform analyzes denial letters, identifies the specific denial basis, and creates evidence-backed appeals aligned to each plan's own coverage policies. For complex cases like Strensiq appeals, we help patients and clinicians navigate the prior authorization process with targeted documentation and strategic appeal letters that address payer-specific requirements.

This guide provides educational information and should not be considered medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. For official appeals guidance specific to your Cigna plan, consult your plan documents or contact Cigna member services directly.

Sources & Further Reading

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