By Counterforce Health Team in Strensiq (asfotase alfa) —

How to Get Strensiq (asfotase alfa) Covered by Cigna in Illinois: Decision Tree, Appeals, and Next Steps

Answer Box: Your Path to Strensiq Coverage in Illinois

Cigna requires strict prior authorization for Strensiq (asfotase alfa) for pediatric-onset hypophosphatasia (HPP). You qualify if you have documented perinatal, infantile, or juvenile-onset HPP with low alkaline phosphatase and genetic confirmation. Next steps: (1) Gather diagnostic proof including ALPL mutation testing, (2) Have your specialist submit a comprehensive prior authorization request, (3) If denied, appeal within 180 days using Illinois's strong external review rights. Start by confirming your diagnosis meets Cigna's pediatric-onset criteria.

Table of Contents

How to Use This Decision Tree

This guide walks you through Cigna's requirements for Strensiq (asfotase alfa) coverage in Illinois step by step. Start with the eligibility triage below to see where you stand. Each section gives you specific documents to gather and next steps to take.

Important: Strensiq is only FDA-approved for perinatal, infantile, and juvenile-onset hypophosphatasia. Adult-onset HPP is typically not covered by insurance.

Eligibility Triage: Do You Qualify?

Answer these questions to find your path:

1. Age at HPP Symptom Onset

2. Diagnosis Confirmation

3. Alkaline Phosphatase Levels

  • Below age/sex-adjusted normal range: Continue to question 4 ✓
  • Normal or high levels: Go to "Not Yet Eligible"

4. Clinical Evidence

Do you have documented HPP symptoms before age 18?

If You're Likely Eligible: Document Checklist

You meet Cigna's basic criteria. Here's what to gather for your prior authorization:

Required Documents

  • Genetic test results showing pathogenic ALPL mutation
  • Lab reports with alkaline phosphatase below normal range
  • Medical records documenting HPP symptoms before age 18
  • Specialist consultation from endocrinologist or metabolic specialist
  • Imaging studies showing bone abnormalities (if available)
  • Treatment history of failed supportive therapies

Submission Process

  1. Your specialist submits the prior authorization request through Cigna's provider portal
  2. Timeline: Cigna has 15 business days for standard reviews, 24-72 hours for urgent requests
  3. Follow up: Call Cigna member services if you don't hear back within the timeframe
Tip: Ask your doctor to request expedited review if your condition is rapidly progressing or life-threatening.

If You're Possibly Eligible: Tests to Request

You may qualify but need additional testing. Request these from your healthcare team:

Missing Genetic Testing

  • ALPL gene sequencing to identify pathogenic mutations
  • Timeline: Results typically take 2-4 weeks
  • Coverage: Most insurance covers genetic testing for suspected HPP

Incomplete Clinical Documentation

  • Comprehensive bone imaging (X-rays, bone scans)
  • Detailed medical history review to establish symptom onset timing
  • Specialist evaluation by endocrinologist familiar with HPP

What to Track While Testing

  • Keep a symptom diary noting bone pain, fractures, dental issues
  • Document medication trials and their outcomes
  • Save all lab results showing low alkaline phosphatase over time

Timeline to Re-apply: Plan for 6-8 weeks to complete testing and resubmit your request.

If You're Not Yet Eligible: Alternative Options

If you don't meet standard criteria, you still have options:

Exception Request Process

  • Submit a formulary exception request with compelling clinical rationale
  • Include peer-reviewed literature supporting off-label use
  • Consider compassionate use programs through the manufacturer

Supportive Therapies to Document

While pursuing coverage, try these treatments and document outcomes:

  • Physical therapy for mobility issues
  • Calcium and vitamin D supplementation
  • Pain management strategies
  • Orthopedic interventions for fractures

Building Your Case

  • Specialist opinions from multiple HPP experts
  • Quality of life assessments showing disease impact
  • Economic arguments about preventing complications

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed rebuttals that align with each plan's own coverage rules.

If You're Denied: Illinois Appeal Process

Illinois gives you strong rights to challenge denials. Here's your roadmap:

Step 1: Internal Appeal (First Level)

  • Deadline: 180 days from denial date
  • How to file: Submit written appeal to Cigna's National Appeals Unit
  • Required: Copy of denial letter, medical records, specialist letter
  • Timeline: Cigna responds within 60 days

Step 2: External Review (Independent)

If your internal appeal fails, Illinois law guarantees an independent review:

  • Deadline: 30 days after final internal denial (shorter than most states)
  • How to file: Request forms from Illinois Department of Insurance
  • Cost: Free to you (insurer pays review costs)
  • Timeline: Decision within 5 business days after reviewer gets records

Step 3: Get Help

  • Illinois Department of Insurance: (877) 527-9431 for guidance
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • Legal aid: For complex cases needing attorney support
Critical: Illinois's 30-day deadline for external review is shorter than many states. Don't delay after an internal appeal denial.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna formulary documents Cigna PA List
Pediatric Onset Only Symptoms before age 18 Medical records, specialist notes Cigna Coverage Policy
ALPL Mutation Genetic confirmation required Lab genetic testing report Cigna Coverage Policy
Low Alkaline Phosphatase Below age/sex normal range Laboratory test results Cigna Coverage Policy
Specialist Requirement Endocrinologist or metabolic specialist Provider credentials, referral Cigna Coverage Policy
Dosing Limits Maximum 9 mg/kg/week Prescription details FDA Label

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Adult-onset HPP not covered" Prove symptom onset before age 18 Childhood medical records, parent/caregiver statements
"Insufficient genetic evidence" Submit comprehensive ALPL testing Full gene sequencing report with pathogenic variant
"Experimental/investigational" Cite FDA approval for pediatric HPP FDA approval letter, clinical guidelines
"Not medically necessary" Document disease severity and impact Imaging studies, functional assessments, specialist letters
"Dosing exceeds guidelines" Justify higher dose with clinical response Treatment response data, specialist rationale

FAQ: Your Top Questions Answered

How long does Cigna prior authorization take in Illinois? Standard reviews take up to 15 business days. Urgent requests get decisions within 24-72 hours. You can request expedited review if delays would jeopardize your health.

What if Strensiq is non-formulary on my plan? Request a formulary exception with clinical justification. Include evidence that formulary alternatives are inappropriate or ineffective for HPP.

Can I appeal if I live in Illinois but have coverage from another state? Yes, if you receive care in Illinois. However, your appeal rights depend on where your insurance policy is issued. Check with your plan administrator.

Does Cigna require step therapy for Strensiq? No, there are no alternative HPP enzyme replacement therapies. However, they may require documentation of failed supportive treatments.

What's the cost without insurance coverage? Strensiq costs approximately $10,000+ per vial, with annual costs potentially reaching $500,000-$4.9 million depending on weight and dosing. Patient assistance programs may help with costs.

How do I find an HPP specialist in Illinois? Contact endocrinology departments at major medical centers like Northwestern Memorial, University of Chicago Medicine, or Rush University Medical Center.

From our advocates: We've seen families succeed after initial denials by gathering comprehensive childhood medical records that clearly document early symptom onset. One family found crucial evidence in pediatric dental records showing premature tooth loss—a classic HPP sign that helped prove their case wasn't adult-onset.

When to Get Help

Consider professional assistance if:

  • Your case involves complex medical history or borderline eligibility
  • You've received multiple denials despite meeting criteria
  • You're facing tight appeal deadlines
  • You need help navigating Illinois's external review process

Resources:

  • Illinois Department of Insurance: (877) 527-9431
  • Rare disease patient advocates: Contact NORD or Soft Bones Foundation
  • Legal assistance: Illinois legal aid organizations for insurance disputes

For complex prior authorization cases, Counterforce Health helps patients and clinicians turn denials into successful appeals by identifying specific denial reasons and creating evidence-backed responses tailored to each insurer's coverage policies.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage criteria change frequently. Always verify current requirements with Cigna and consult healthcare professionals for medical decisions. For official Illinois insurance appeals information, visit the Illinois Department of Insurance website.

Sources & Further Reading:

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