By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Cigna in Ohio: Complete Prior Authorization Guide with Forms and Appeals

Quick Answer: Cigna covers Tagrisso (osimertinib) for EGFR-mutated NSCLC with prior authorization requiring FDA-approved EGFR testing results. Submit through EviCore by Evernorth or fax to 1-800-882-4462. If denied, file internal appeal within 180 days, then Ohio external review within 180 days of final denial. Start by gathering your EGFR mutation test results and having your oncologist contact Cigna today.

Table of Contents

Coverage Basics: Is Tagrisso Covered?

Yes, Cigna covers Tagrisso (osimertinib) with prior authorization for FDA-approved NSCLC indications. The drug is classified as Tier 4 Specialty with mandatory PA under Cigna's National Formulary Coverage policy CNF-550.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all uses Cigna provider portal/EviCore CNF-550 Policy
EGFR Testing FDA-approved test showing specific mutations Pathology report from CLIA lab CNF-550 Policy
Formulary Tier Tier 4 Specialty (SP) Plan formulary document 2025 Formulary
Step Therapy None at national level May vary by employer plan CNF-550 Policy
Age Restriction 18 years and older All indications CNF-550 Policy

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm EGFR Mutation Status (Patient/Oncologist)
    • Ensure you have FDA-approved test results showing EGFR exon 19 deletions, L858R, or T790M
    • Document: Pathology report from CLIA-certified lab
    • Timeline: Test results needed before PA submission
  2. Gather Clinical Documentation (Oncologist's Office)
    • Diagnosis confirmation with ICD-10 codes
    • Treatment history and prior therapy outcomes
    • NCCN guideline references (version 3.2025)
    • Timeline: 1-2 business days to compile
  3. Submit Prior Authorization (Prescriber)
    • Portal: EviCore by Evernorth (select "Medical Oncology Pathways")
    • Alternative: Fax to 1-800-882-4462
    • Timeline: Same-day submission possible
  4. Track PA Status (Patient/Clinic)
    • Check EviCore portal or call Cigna member services
    • Timeline: Decision within 72 hours (24 hours if expedited)
  5. Receive Approval (All Parties)
    • Duration: 1 year for advanced/metastatic, 3 years total for adjuvant
    • Renewal: Submit 4-6 weeks before expiration

Required Documentation & Testing

EGFR Mutation Testing Requirements

Cigna requires FDA-approved EGFR testing with specific mutations documented:

For First-Line Advanced/Metastatic NSCLC:

  • EGFR exon 19 deletions OR
  • EGFR exon 21 L858R substitution

For T790M-Positive Disease:

  • T790M mutation after progression on prior EGFR TKI
  • May include uncommon mutations (L861Q, G719X, S768I)

For Adjuvant Post-Resection:

  • EGFR exon 19 deletions OR L858R
  • Completely resected stage IB-IIIA NSCLC
Clinician Corner: Your medical necessity letter should include: (1) specific EGFR mutation with test method, (2) disease stage and resection status, (3) prior treatment history with outcomes, (4) NCCN guideline citation supporting Tagrisso use, and (5) planned monitoring schedule. Reference the FDA label and current NCCN guidelines.

Timing & Urgency

Standard vs. Expedited Review

Standard Prior Authorization:

  • Timeline: 72 hours from complete submission
  • Use when: Stable disease, planned treatment start

Expedited Review:

  • Timeline: 24 hours from submission
  • Use when: Urgent medical need, delay could jeopardize health
  • Request: Specify "expedited/urgent" in PA submission

When Treatment Can't Wait

If you need Tagrisso immediately while PA is pending:

  1. Request expedited review citing medical urgency
  2. Consider Counterforce Health's rapid appeal services for complex cases
  3. Explore manufacturer patient assistance for bridge supply
  4. Document all costs for potential reimbursement after approval

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
No EGFR mutation documented Submit FDA-approved test results CLIA lab pathology report
Wrong treatment setting Clarify first-line vs. adjuvant indication Staging studies, surgical reports
Insufficient prior therapy Document treatment history for T790M cases Pharmacy records, oncology notes
Missing clinical information Complete PA with all required fields Diagnosis codes, treatment plan
Non-formulary status File formulary exception request Medical necessity letter, guidelines

Appeals Process in Ohio

Internal Appeals with Cigna

First-Level Internal Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 15 business days for decision (72 hours if expedited)
  • Submit: Written request with denial letter and supporting records
  • Contact: Cigna member services or provider portal

Second-Level Internal Appeal:

  • Available if first appeal denied
  • Same deadlines and timelines as first level
  • Include additional clinical evidence or peer-reviewed studies

Ohio External Review Process

After exhausting internal appeals, Ohio residents can request external review through an Independent Review Organization (IRO).

Standard External Review:

  • Deadline: 180 days from final internal denial
  • Timeline: 30 days for IRO decision
  • Process: Submit written request to Cigna, who forwards to Ohio Department of Insurance
  • Binding: IRO decision is final and binding on Cigna

Expedited External Review:

  • Available when delay would seriously endanger health
  • Timeline: 72 hours for IRO decision
  • Process: Oral request accepted, treating physician must certify urgency
Contact Ohio Department of Insurance: Call 1-800-686-1526 for external review questions or assistance with the process.

Specialty Pharmacy Requirements

Cigna Accredo Enrollment

Most Cigna plans require Tagrisso to be filled through Accredo specialty pharmacy after initial retail fills.

Enrollment Process:

  1. Prescriber completes Accredo Prescription & Enrollment Form
  2. Fax completed form to 888-302-1028
  3. Include patient demographics, clinical information, and prescription details
  4. Accredo patient advocate calls to complete enrollment and schedule delivery

Required Information:

  • ICD-10 diagnosis codes
  • Patient weight and allergies
  • Prescription strength, directions, and quantity
  • Infusion location if applicable

Patient Contact:

  • Accredo enrollment: 877-826-7657
  • Patient portal: MyAccredoPatients.com
  • 24/7 support: 844-516-3319

Cost Savings & Patient Assistance

Manufacturer Support Programs

AstraZeneca Tagrisso Co-Pay Savings Program:

  • Benefit: $0 copay for commercially insured patients
  • Enrollment: Call 844-275-2360 or visit MyAccess360.com
  • Eligibility: Commercial insurance required (not Medicare/Medicaid)

AZ&Me Program:

  • Benefit: Free medication for uninsured patients
  • Eligibility: Income-based qualification
  • Application: Through MyAccess360.com

Foundation Grants

  • CancerCare Co-Payment Assistance Foundation
  • Patient Access Network Foundation
  • Good Days Foundation

Eligibility varies by income, diagnosis, and available funding.

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Cigna refuses to process your external review request
  • Appeals deadlines are not being met
  • You need help understanding your appeal rights
  • Cigna claims your case isn't eligible for external review

Ohio Department of Insurance Consumer Services:

  • Phone: 1-800-686-1526
  • Website: insurance.ohio.gov
  • Services: External review assistance, complaint filing, appeals guidance

For complex cases requiring specialized expertise, Counterforce Health provides professional appeal services that turn insurance denials into targeted, evidence-backed appeals using payer-specific workflows and clinical documentation.

Frequently Asked Questions

How long does Cigna prior authorization take in Ohio? Standard PA decisions are issued within 72 hours; expedited reviews within 24 hours for urgent cases.

What if Tagrisso is non-formulary on my plan? Request a formulary exception with clinical justification showing medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if delays could jeopardize your health. Your treating physician must certify the urgency in writing.

Does step therapy apply to Tagrisso? Cigna's national policy has no step therapy requirement, but individual employer plans may impose additional restrictions.

What EGFR mutations qualify for coverage? Exon 19 deletions, L858R substitution, and T790M (after prior TKI progression) are the primary qualifying mutations.

How do I transfer my prescription to Accredo? Ask your oncologist to send the prescription directly to Accredo, or call 800-803-2523 to initiate the transfer.

What happens if I miss an appeal deadline? Ohio allows 180 days for external review even if you miss internal appeal deadlines, but act quickly to preserve all rights.

Can I get help with the appeal process? Yes, contact Ohio Department of Insurance at 1-800-686-1526 or consider professional appeal services for complex cases.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan documents for specific coverage details. Appeal rights and processes may vary by plan type.

Sources & Further Reading

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