By Counterforce Health Team in Strensiq (asfotase alfa) —

How to Get Strensiq (Asfotase Alfa) Covered by Cigna in Texas: PA Requirements, Appeals, and Approval Strategy

Answer Box: Getting Strensiq (Asfotase Alfa) Covered by Cigna in Texas

Strensiq requires prior authorization (PA) from Cigna for all Texas plans. The fastest approval path: (1) Confirm pediatric-onset hypophosphatasia with genetic testing showing ALPL mutation and low ALP levels, (2) Have a geneticist or endocrinologist complete Cigna's PA form with full clinical documentation, (3) Submit through Accredo specialty pharmacy or Cigna's provider portal. Most approvals take 3-7 business days with complete documentation. If denied, Texas law guarantees internal appeals (180 days) and independent external review through the Texas Department of Insurance.

Table of Contents

Plan Types & Coverage Differences

Cigna offers HMO, PPO, and EPO plans in Texas, each with distinct rules for specialty drug coverage:

Plan Type Network Requirements Referrals Needed Specialty Drug Access
HMO In-network only Yes, from PCP Accredo or in-network specialty pharmacy only
PPO In/out-network (higher cost out) No Broader pharmacy access, higher cost out-of-network
EPO In-network only Generally no In-network specialty pharmacies only
Note: All plan types require prior authorization for Strensiq regardless of network status. Out-of-network coverage (PPO only) doesn't bypass PA requirements.

For Strensiq specifically, most Cigna plans in Texas route specialty medications through Accredo, their preferred specialty pharmacy partner.

Formulary Status & Tier Placement

Strensiq is listed on Cigna's National Preferred 4-Tier Specialty Prescription Drug List as:

  • Tier 4 (Brand Specialty)
  • PA required (prior authorization)
  • SP designation (specialty medication)
  • No step therapy required

This tier placement means you'll pay coinsurance (typically 25-40%) rather than a flat copay, and the medication must be dispensed through a specialty pharmacy.

Prior Authorization Requirements

Cigna's medical necessity criteria for Strensiq are strict and well-defined. According to their coverage policy, approval requires:

Required Documentation

Genetic Confirmation:

  • Molecular genetic testing showing pathogenic ALPL gene mutation
  • If genetic testing unavailable, elevated substrate levels (pyridoxal 5'-phosphate or urinary inorganic pyrophosphate)

Biochemical Evidence:

  • Low serum alkaline phosphatase (ALP) activity using age- and sex-adjusted pediatric reference ranges
  • Lab results must be recent (typically within 6 months)

Clinical Evidence (onset before age 18):

  • Skeletal abnormalities or non-traumatic fractures
  • Premature loss of primary teeth (before age 4)
  • Muscle weakness or hypotonia
  • Respiratory problems
  • Vitamin B6-dependent seizures
  • Failure to thrive or growth issues

Prescriber Requirements:

  • Must be prescribed by or in consultation with:
    • Geneticist
    • Endocrinologist
    • Metabolic disease subspecialist
    • Physician with documented HPP expertise

Dosing Justification

Standard FDA dosing is 6 mg/kg/week subcutaneously in divided doses. Higher doses (up to 9 mg/kg/week) require clinical justification for severe disease.

Clinician Corner: Your medical necessity letter should address each criterion explicitly. Include specific lab values with reference ranges, document the timeline of symptom onset, and cite relevant treatment guidelines. The FDA label provides comprehensive clinical trial data to support your rationale.

Specialty Pharmacy Setup

Most Cigna plans require Strensiq to be dispensed through Accredo specialty pharmacy. Here's the enrollment process:

Step-by-Step Enrollment

  1. Prescription Referral
  2. Patient Onboarding
    • Accredo patient advocate calls within 24-48 hours
    • Verifies information and schedules first delivery
    • Discusses copay assistance programs
  3. Account Setup
    • Register at MyAccredoPatients.com after first prescription
    • Manage refills and shipments online
    • Access 24/7 pharmacist support
  4. Insurance Coordination
    • Accredo processes PA with Cigna
    • Coordinates with prescriber for additional documentation if needed
    • Handles appeals if initial PA is denied

For questions, Cigna members can call Accredo at 877-826-7657.

Cost-Share Basics

As a Tier 4 specialty medication, Strensiq typically requires coinsurance rather than a flat copay:

  • Typical coinsurance: 25-40% after deductible
  • Annual cost: Can exceed $500,000-$1,000,000+ depending on weight and dosing
  • Deductible: May apply before coinsurance kicks in

Financial Assistance Options

Manufacturer Support:

Foundation Grants:

  • Independent charitable foundations may provide assistance
  • Accredo's financial support team coordinates applications
Important: Copay assistance availability depends on your insurance type and income. Government insurance (Medicare/Medicaid) typically excludes manufacturer copay cards.

Submission Process

For Providers

Cigna Provider Portal:

  • Log in to Cigna for Health Care Providers
  • Navigate to Prior Authorization section
  • Complete electronic PA form with all required attachments

Alternative Submission:

  • Fax PA requests to Cigna Pharmacy Services: 1-855-476-4158 (verify current number with Cigna)
  • Include completed PA form, clinical notes, lab results, and genetic testing

Required Fields

When completing the PA form, ensure these fields are thoroughly documented:

  • Patient demographics and Cigna member ID
  • Diagnosis with ICD-10 codes
  • Prescriber information and specialty
  • Detailed clinical history with onset timeline
  • Laboratory results (ALP levels with reference ranges)
  • Genetic testing results
  • Prior treatment attempts and outcomes
  • Dosing rationale

Common Approval Patterns

Based on Cigna's coverage patterns, successful submissions typically include:

Strong Documentation Package

Medical Records:

  • Comprehensive clinical notes documenting symptom onset before age 18
  • Growth charts showing failure to thrive (if applicable)
  • Imaging studies showing skeletal abnormalities
  • Dental records documenting premature tooth loss

Laboratory Evidence:

  • Serial ALP measurements showing consistently low levels
  • Genetic testing report with pathogenic ALPL variants
  • Additional biochemical markers if available

Treatment History:

  • Documentation of supportive care attempts (calcium, vitamin D)
  • Response to previous treatments
  • Contraindications to alternative approaches

Common Denial Reasons & Solutions

Denial Reason Solution
Insufficient genetic confirmation Submit complete genetic testing report showing ALPL mutation
Adult-onset HPP Provide documentation of symptom onset before age 18
Incomplete clinical documentation Submit comprehensive medical records with detailed symptom timeline
Non-specialist prescriber Obtain consultation with geneticist or endocrinologist

Appeals Process in Texas

If your initial PA is denied, Texas law provides strong appeal rights:

Internal Appeals

Timeline: Must file within 180 days of denial Process:

  1. Submit written appeal to Cigna
  2. Include additional medical documentation
  3. Request peer-to-peer review with medical director
  4. Cigna has 30 days to respond (pre-service) or 60 days (post-service)

External Review

If internal appeals are denied, you can request independent external review through the Texas Department of Insurance:

Eligibility: Available for medical necessity denials Timeline: File within 4 months of final internal denial Process:

  • Cigna provides IRO request form with final denial
  • Submit to Independent Review Organization
  • Decision rendered within 20 days (5 days for urgent cases)
  • IRO decision is binding on Cigna

Contact Information:

  • Texas Department of Insurance: 1-800-252-3439
  • IRO Information Line: 1-866-554-4926
From our advocates: We've seen families succeed on appeal by submitting additional clinical photos showing skeletal deformities and obtaining letters from multiple specialists confirming the pediatric-onset diagnosis. The key is demonstrating that symptoms clearly began before age 18, even if the formal diagnosis came later. Always include growth charts and developmental milestone records when available.

Frequently Asked Questions

How long does Cigna PA take in Texas? Standard PA decisions are made within 3-7 business days with complete documentation. Expedited reviews (for urgent cases) are processed within 24-72 hours.

What if Strensiq is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Include documentation that supportive care alone is insufficient.

Can I request an expedited appeal? Yes, if a delay would jeopardize your health. Submit expedited internal and external appeals simultaneously for urgent cases.

Does step therapy apply? No, Cigna doesn't require step therapy for Strensiq since there are no therapeutic alternatives for HPP.

What happens if I move from another state? Previous approvals may not transfer. Submit new PA with complete documentation, including records of treatment response from your previous state.

Can adults get coverage? Cigna typically covers only pediatric-onset HPP. Adults must demonstrate symptom onset before age 18 with comprehensive medical records.

How often is reauthorization required? Most plans require annual reauthorization with documentation of continued medical necessity and treatment response.

When to Get Help

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and procedural details that improve approval rates. For complex cases like Strensiq, having expert appeal support can make the difference between coverage and costly out-of-pocket payments.

If you need additional support with your Cigna appeal in Texas:

State Resources:

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas (for Medicaid appeals)

Professional Support:

  • Counterforce Health for comprehensive appeal assistance
  • Healthcare advocates specializing in rare disease coverage

Sources & Further Reading

This guide provides educational information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company to understand your specific benefits. Coverage policies and requirements may change; verify current information with Cigna directly.

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