By Counterforce Health Team in Symdeko / Symkevi (tezacaftor/ivacaftor) —

How to Get Symdeko/Symkevi Covered by Cigna in Illinois: Prior Authorization Forms, Appeals Timeline & Documentation Guide

Quick Answer: Getting Symdeko/Symkevi Approved by Cigna in Illinois

Eligibility: Cigna covers Symdeko (tezacaftor/ivacaftor) for cystic fibrosis patients age 6+ with specific CFTR mutations, prescribed by a pulmonologist or CF specialist. Fastest path: Have your CF specialist submit prior authorization with genetic testing results, clinical notes, and medical necessity letter via CoverMyMeds or fax to 1-866-873-8279. First step today: Gather your genetic test results showing eligible mutations (E56K, P67L, R74W, D110E, D110H, R117C, E193K, L206W, R347H, R352Q, or others listed in Cigna's criteria) and schedule an appointment with your CF specialist to initiate the PA request.

Table of Contents

  1. Coverage at a Glance
  2. Before You Start: Verify Your Plan
  3. Gather Required Documentation
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Illinois
  7. If You Need to Provide More Information
  8. If Your Request is Denied
  9. Appeals Process in Illinois
  10. Renewal and Re-Authorization
  11. FAQ: Common Questions
  12. Quick Reference Checklist

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Cigna plans Cigna PA Policy
Age Requirement 6 years or older FDA labeling, medical records
Genetic Testing FDA-cleared CFTR mutation test showing eligible mutations Lab results, genetic counselor report
Prescriber Pulmonologist or CF specialist required Provider credentials, consultation notes
Authorization Duration 1 year when approved Cigna policy
Internal Appeal Deadline 180 days from denial Illinois DOI guidance
External Review Deadline 4 months from final denial Illinois Health Carrier External Review Act

Before You Start: Verify Your Plan

Check your specific Cigna plan type since requirements can vary. Most Cigna members have their specialty drugs managed through Express Scripts or Accredo specialty pharmacy.

Key steps:

  1. Log into myCigna.com or call member services at 1-800-244-6224
  2. Verify Symdeko is on your formulary (it's typically Tier 4 or 5 specialty)
  3. Confirm your pharmacy benefit is through Express Scripts
  4. Check if you have any existing step therapy requirements
Note: Some employer plans may require trying Trikafta first if you have mutations covered by both medications.

Gather Required Documentation

Your CF specialist will need these documents to submit a complete prior authorization:

Essential Clinical Documentation

  • Genetic test results showing eligible CFTR mutations (FDA-cleared testing required)
  • CF diagnosis confirmation with ICD-10 code E84.9 (cystic fibrosis, unspecified)
  • Current clinical notes from pulmonologist or CF specialist
  • Recent pulmonary function tests (FEV1, FVC)
  • Sweat chloride test results (if available)
  • Prior CFTR modulator history and outcomes

Specialist Requirements

Symdeko must be prescribed by or in consultation with:

  • Board-certified pulmonologist, OR
  • Physician specializing in cystic fibrosis treatment

Medical Necessity Letter Components

Your specialist should include:

  • Patient's specific CFTR genotype and why Symdeko is appropriate
  • Disease severity and current symptoms
  • Previous treatments tried and outcomes
  • Expected benefits of Symdeko therapy
  • References to CF Foundation guidelines and FDA labeling

Submit the Prior Authorization Request

Submission Methods (Provider Only)

Prescribers can submit via:

  1. Online: CoverMyMeds portal
  2. EHR integration: SureScripts electronic prior authorization
  3. Fax: 1-866-873-8279
  4. Phone: 1-800-882-4462

Complete Request Packet Checklist

  • ✅ Completed PA form with all required fields
  • ✅ Genetic testing results (FDA-cleared lab)
  • ✅ Specialist consultation notes
  • ✅ Medical necessity letter
  • ✅ Recent clinical notes and lab values
  • ✅ Insurance card copy and patient demographics
Tip: Incomplete submissions are the #1 cause of delays. Double-check all required fields before submitting.

Follow-Up and Tracking

When to Call Cigna

  • 72 hours after submission if no acknowledgment received
  • Day 3-5 to check processing status
  • If approaching decision deadline and no response

What to Ask When Calling

  1. "Can you confirm receipt of PA request for [patient name], submitted on [date]?"
  2. "What's the reference number for tracking?"
  3. "Is any additional information needed?"
  4. "What's the expected decision date?"

Sample Call Script

"Hi, I'm calling to check on a prior authorization request for Symdeko submitted on [date] for patient [name]. The member ID is [number]. Can you provide the status and reference number?"

Document everything: Keep notes of call dates, representative names, and reference numbers.

Typical Timelines in Illinois

Standard Review Process

  • Cigna decision timeframe: 72 hours for standard requests
  • Expedited reviews: 24 hours (for urgent medical situations)
  • Illinois requirement: Insurers must respond within mandated timeframes or request is deemed approved

What Speeds Up Approval

  • Complete documentation on first submission
  • Clear medical necessity rationale
  • Specialist involvement from the start
  • FDA-cleared genetic testing results

What Causes Delays

  • Missing genetic test results
  • Incomplete specialist documentation
  • Non-FDA approved testing methods
  • Generic medical necessity letters

If You Need to Provide More Information

Common requests from Cigna:

  • Additional genetic testing details
  • More specific mutation documentation
  • Updated pulmonary function tests
  • Clarification on prior treatments

How to respond:

  1. Act quickly - you typically have 14 days to provide additional information
  2. Be thorough - include all requested documents plus supporting materials
  3. Resubmit properly - use the same reference number and submission method

Handling Medical Necessity Questions

If Cigna questions medical necessity, your specialist should provide:

  • Updated clinical assessment
  • References to peer-reviewed literature
  • Comparison to treatment alternatives
  • Expected outcomes with Symdeko therapy

If Your Request is Denied

Common Denial Reasons & Solutions

Denial Reason How to Fix
Missing genetic testing Submit FDA-cleared CFTR mutation analysis
Age requirement not met Verify patient is 6+ years with birth certificate
Non-specialist prescriber Get consultation/prescription from pulmonologist
Insufficient documentation Provide comprehensive clinical notes and rationale
Step therapy required Document failure/intolerance of required first-line therapy

First-Level Appeal Preparation

  • Review denial letter carefully for specific reasons
  • Gather additional supporting documentation
  • Consider requesting peer-to-peer review with Cigna medical director
  • Submit appeal within 180 days of denial

Appeals Process in Illinois

Illinois residents have strong appeal rights under state law. Here's your pathway:

Internal Appeal with Cigna

  • Deadline: 180 days from denial date
  • Decision timeframe: 15 business days (24 hours for expedited)
  • Submit to: Cigna National Appeals Unit
  • Required: Written appeal with supporting documentation

External Review (After Internal Appeal)

  • Deadline: 4 months from Cigna's final denial
  • Process: Independent physician review through Illinois Department of Insurance
  • Timeline: 45 days for decision (72 hours for expedited)
  • Cost: Free to patients
  • Forms: Illinois DOI External Review Request

Illinois-Specific Resources

  • Illinois Department of Insurance Consumer Helpline: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • Both can help with appeal preparation and insurer communication
Important: Illinois has a shorter external review deadline (4 months) compared to many states. Don't delay if your internal appeal is denied.

Renewal and Re-Authorization

When to Start Renewal Process

  • 11 months after initial approval
  • 30-60 days before current authorization expires
  • Set calendar reminders to avoid treatment interruption

Renewal Documentation Needed

  • Updated clinical notes showing continued medical necessity
  • Current pulmonary function tests
  • Treatment response assessment
  • Any changes in condition or other therapies

What Helps Renewal Approval

  • Document clinical improvement or stability on Symdeko
  • Show continued specialist oversight
  • Include quality of life improvements
  • Reference ongoing CF Foundation guidelines

FAQ: Common Questions

Q: How long does Cigna prior authorization take in Illinois? A: Standard requests: 72 hours. Expedited requests: 24 hours. Illinois law requires insurers to meet these deadlines or the request may be deemed approved.

Q: What if Symdeko isn't on my Cigna formulary? A: You can request a formulary exception with medical necessity documentation. Your specialist will need to show why Symdeko is medically necessary compared to formulary alternatives.

Q: Can I request an expedited appeal in Illinois? A: Yes, if delay in treatment would seriously jeopardize your health. Both Cigna internal appeals and Illinois external reviews have expedited pathways.

Q: Does step therapy apply if I've tried other CFTR modulators outside Illinois? A: Yes, prior treatment history from any state counts. Document all previous CFTR modulators tried, including dates, duration, and outcomes.

Q: What if my genetic testing was done years ago? A: As long as it was FDA-cleared testing and shows eligible mutations, older genetic testing is typically acceptable. Your CF center can provide updated documentation if needed.

Q: Can I appeal if I'm denied due to my specific mutation not being listed? A: Yes. If you have "two CF-causing CFTR mutations" or "abnormal nasal potential difference," you may still qualify even if your specific mutations aren't individually listed.

Quick Reference Checklist

Before Starting

  • Verify Cigna plan covers specialty drugs
  • Confirm CF specialist is in-network
  • Gather genetic testing results
  • Review current formulary status

Documentation Needed

  • FDA-cleared CFTR genetic testing
  • CF specialist consultation notes
  • Medical necessity letter
  • Recent pulmonary function tests
  • Prior treatment history
  • Insurance card and demographics

Submission Process

  • Specialist submits via CoverMyMeds, fax, or phone
  • Track submission with reference number
  • Follow up within 72 hours
  • Respond quickly to any information requests

If Denied

  • Review denial letter thoroughly
  • File internal appeal within 180 days
  • Consider peer-to-peer review
  • Prepare for external review if needed
  • Contact Illinois DOI for assistance

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements, significantly improving approval rates for complex medications like Symdeko.

When facing a Symdeko denial, Counterforce Health can help identify the specific denial basis—whether it's PA criteria, step therapy, or medical necessity—and draft point-by-point rebuttals using the right clinical evidence and payer-specific workflows.

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 benefits and medical circumstances. Always consult with your healthcare provider and insurance company for specific coverage determinations. For personalized assistance with appeals, contact the Illinois Department of Insurance Consumer Helpline at 877-527-9431.

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