By Counterforce Health Team in Tagrisso (osimertinib) —

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

Answer Box: Getting Tagrisso Covered by Cigna in Pennsylvania

Cigna covers Tagrisso (osimertinib) with prior authorization for EGFR mutation-positive NSCLC. Your fastest path to approval:

  1. Confirm EGFR mutation status via FDA-approved testing (exon 19 deletion, L858R, or T790M)
  2. Submit PA through Cigna provider portal using form CNF-550 with mutation results and clinical notes
  3. If denied, file internal appeal within 180 days and request peer-to-peer review

Pennsylvania residents benefit from a state-run external review program with a 50% overturn rate if internal appeals fail. Start today by contacting your oncologist to verify EGFR testing and initiate the PA process.

Table of Contents

  1. Is Tagrisso Covered by Cigna?
  2. Prior Authorization Process
  3. Required Documentation
  4. Timing and Deadlines
  5. Common Denial Reasons
  6. Appeals Process in Pennsylvania
  7. Specialty Pharmacy Requirements
  8. Cost and Financial Assistance
  9. When to Escalate
  10. FAQ

Is Tagrisso Covered by Cigna?

Yes, Cigna covers Tagrisso (osimertinib) on its National Preferred 3-Tier Formulary, but requires prior authorization (PA) and has quantity limits. Coverage applies for these FDA-approved indications:

  • First-line metastatic NSCLC with EGFR exon 19 deletion or exon 21 L858R mutations
  • Adjuvant therapy after surgical resection for EGFR exon 19/L858R-positive NSCLC
  • Second-line therapy for T790M-positive NSCLC after progression on erlotinib, gefitinib, afatinib, or dacomitinib

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications Cigna CNF-550 Policy
Formulary Tier National Preferred 3-Tier with PA/QL Cigna Formulary
Step Therapy Required for T790M+ after prior TKI failure Cigna CNF-550 Policy
Quantity Limits 80mg daily; overrides available Cigna DQM Policy

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm EGFR Testing (Patient/Oncologist)
    • Ensure FDA-approved test shows sensitizing mutations
    • Document: exon 19 deletion, L858R, or T790M status
    • Timeline: Same day if results available
  2. Gather Clinical Documentation (Oncologist's Office)
    • Pathology report with NSCLC diagnosis and stage
    • Prior therapy history (if applicable for step therapy)
    • Current performance status and treatment goals
    • Timeline: 1-2 business days
  3. Submit PA Request (Oncologist)
    • Use Cigna CNF-550 form
    • Submit via Cigna provider portal or fax
    • Timeline: Same day submission
  4. Cigna Review Period
    • Standard review: 15 business days
    • Expedited (urgent): 72 hours if medically necessary
    • Timeline: 2-3 weeks typically
  5. Approval or Denial Notification
    • Sent to prescriber and patient
    • If approved: prescription can be filled
    • If denied: appeal window opens (180 days)

Required Documentation

Medical Necessity Checklist

Your oncologist must provide:

Essential Clinical Information:

  • ✅ EGFR mutation status via FDA-approved testing
  • ✅ Histologic confirmation of NSCLC with staging
  • ✅ Performance status (ECOG 0-2 typically required)
  • ✅ Treatment history for step therapy requirements
  • ✅ Contraindications to alternative therapies (if applicable)

Supporting Documentation:

  • Pathology report with ICD-10 codes
  • Imaging confirming metastatic disease (if applicable)
  • Laboratory values (baseline cardiac function for safety)
  • Prior therapy failure documentation (for T790M+ cases)
Clinician Corner: When writing the medical necessity letter, cite NCCN Guidelines (Category 1 recommendation for first-line EGFR+ NSCLC) and FDA labeling. Include specific mutation type, disease stage, and why Tagrisso is the appropriate choice over alternatives like erlotinib or gefitinib.

Timing and Deadlines

Pennsylvania-Specific Timelines

Process Standard Timeline Expedited Timeline Notes
PA Review 15 business days 72 hours Request expedited if urgent medical need
Internal Appeal 30 days (pre-service) / 60 days (post-service) 72 hours Must file within 180 days of denial
External Review 45 days 72 hours Pennsylvania Insurance Department process
Appeal Deadline 180 days from EOB/denial N/A Clock starts from denial notification

Pennsylvania Advantage: Since January 2024, Pennsylvania operates its own external review program, which has overturned 50% of appealed denials in its first year—significantly higher than many other states.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit FDA-approved test results Tissue/plasma testing report with specific mutation
Step therapy not met Document prior TKI failure or contraindication Treatment history, toxicity reports, progression notes
Not medically necessary Provide NCCN guideline citation Medical necessity letter with Category 1 evidence
Quantity limits exceeded Request override with clinical justification Dosing rationale, drug interaction documentation
Wrong line of therapy Clarify first-line vs. subsequent use Staging, prior treatment timeline

Most Effective Appeal Strategy

Peer-to-peer review has an 80-85% overturn rate for PA denials. Request this by calling Cigna Provider Services at 1-800-88-CIGNA and asking for an expedited appeal with peer-to-peer discussion.

Appeals Process in Pennsylvania

Internal Appeals with Cigna

Level 1 Appeal (Required First Step):

  • Deadline: 180 days from denial date
  • Submit to: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Timeline: 30 days for pre-service, 60 days for post-service
  • Include: Member ID, claim number, clinical justification, supporting evidence

Level 2 Appeal:

  • Deadline: 60 days from Level 1 denial
  • Process: Similar to Level 1 but reviewed by different medical director
  • Strategy: Add new clinical evidence or guidelines not previously submitted

Pennsylvania External Review

If both internal appeals are denied, Pennsylvania residents can request independent external review through the state:

Eligibility:

  • Must have Final Adverse Benefit Determination from Cigna
  • Commercial insurance (not self-funded employer plans)
  • Medical necessity or experimental treatment denials

Process:

  1. Submit request within 4 months of final denial
  2. File online at pa.gov external review portal
  3. Review assignment within 5 business days
  4. Decision timeline: 45 days standard, 72 hours expedited
  5. Submit additional evidence within 15 days of assignment

Success Rate: 50% of external reviews were overturned in favor of patients in 2024, with insurers required to provide coverage immediately upon reversal.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific rules and requirements.

Specialty Pharmacy Requirements

Cigna typically requires Tagrisso to be dispensed through Accredo, their preferred specialty pharmacy, for:

  • Home delivery of 90-day supplies
  • Prior authorization coordination
  • Patient assistance program enrollment
  • Clinical monitoring and adherence support

Key Contacts:

  • Accredo: 1-800-222-6880
  • Cigna Specialty Pharmacy: Verify current preferred pharmacy via member portal
Note: Pennsylvania Medicaid recipients may use state-preferred specialty pharmacies like Chartwell with no copays and free shipping.

Cost and Financial Assistance

Manufacturer Support

AstraZeneca Tagrisso CoPay Program:

  • Covers up to $25,000/year in copays and deductibles
  • Income limits apply (≤500% Federal Poverty Level)
  • Enroll at tagrisso.com/savings-support

Pennsylvania-Specific Programs

  • PA Medicaid Specialty Pharmacy Program: No copays for eligible recipients
  • Hospital financial assistance: Penn Medicine, UPMC, and other health systems offer prescription aid programs
  • Patient Advocate Foundation Co-Pay Relief: Additional copay assistance for qualifying patients

When to Escalate

Contact Pennsylvania Insurance Department if:

  • Cigna doesn't respond within required timelines
  • You suspect unfair claim practices
  • You need help with the external review process

Pennsylvania Insurance Department:

  • Phone: 1-877-881-6388
  • Website: pa.gov insurance services
  • Consumer Services: Available for eligibility questions and process guidance

FAQ

Q: How long does Cigna PA take in Pennsylvania? A: Standard review is 15 business days. Request expedited review (72 hours) if medically urgent.

Q: What if Tagrisso is non-formulary on my plan? A: Submit a formulary exception request with clinical justification. Cigna has a formal exception process for non-covered drugs.

Q: Can I request an expedited appeal? A: Yes, if there's imminent risk to health. Call 1-800-88-CIGNA and explicitly request expedited review with peer-to-peer discussion.

Q: Does step therapy apply if I failed prior TKIs outside Pennsylvania? A: Yes, treatment history from any location counts. Provide documentation of prior therapy failure or intolerance.

Q: What happens if my external review is approved? A: Cigna must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal.

Q: How do I know if my employer plan is self-funded? A: Check with HR or look for "ERISA" language in your plan documents. Self-funded plans aren't eligible for Pennsylvania external review.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. For personalized guidance on navigating insurance appeals and prior authorizations, Counterforce Health helps patients and clinicians turn denials into successful, evidence-backed appeals. Always consult with your healthcare provider and insurance plan for the most current information about your coverage.

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