By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Cigna in Virginia: Prior Authorization Guide and Appeal Timeline

Quick Answer: To get Tagrisso (osimertinib) covered by Cigna in Virginia, you need prior authorization with documented EGFR mutation testing and clinical justification. Submit through Cigna's provider portal with oncology notes, pathology reports, and treatment history. Standard approval takes 72 hours; if denied, Virginia's Bureau of Insurance offers external review within 120 days of final denial. Start by calling Cigna member services at the number on your insurance card to confirm PA requirements and specialty pharmacy network.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna formulary documents Cigna PA Policy
EGFR Mutation Testing Exon 19 deletion or L858R mutation required Pathology report from FDA-approved test FDA Label Requirements
Specialty Pharmacy Must use Express Scripts/Accredo network Member portal or insurance card Express Scripts Network
Annual Renewal PA expires yearly, renew 4-6 weeks early Cigna provider portal Renewal Timeline
Formulary Tier Tier 4 specialty medication Plan-specific formulary Cigna Formulary

Step-by-Step: Fastest Path to Approval

1. Confirm EGFR Mutation Status

Who does it: Oncologist orders testing
Document needed: FDA-approved EGFR mutation test results
Timeline: 5-7 business days for results
Key detail: Must show exon 19 deletion, L858R mutation, or T790M resistance mutation

2. Gather Clinical Documentation

Who does it: Medical team compiles records
Documents needed:

  • Recent oncology visit notes (within 30 days)
  • Pathology report with ICD-10 codes
  • Treatment history and prior therapy failures
  • Current staging and imaging reports

3. Submit Prior Authorization Request

Who does it: Prescriber or clinic staff
How to submit: Cigna provider portal or designated fax
Timeline: Submit 3-5 business days before needed
Expected response: 72 hours for standard requests

4. Monitor Authorization Status

Who does it: Patient or clinic
How to check: Call Cigna member services or check provider portal
Follow-up: Contact within 48 hours if no response received

5. Coordinate Specialty Pharmacy

Who does it: Patient with clinic support
Required step: Transfer prescription to Express Scripts/Accredo network
Timeline: Allow 2-3 business days for first fill

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents to Include
No EGFR mutation documented Submit FDA-approved test results Pathology report with mutation type
Wrong treatment setting Clarify metastatic vs. adjuvant use Staging reports and treatment plan
Insufficient prior therapy Document first-line treatment failures Previous medication trials and outcomes
Missing clinical justification Provide detailed medical necessity letter NCCN guideline citations and rationale
Quantity limit exceeded Request exception with clinical rationale Dosing justification and monitoring plan
From our advocates: We've seen many Tagrisso denials overturned when the oncology team includes specific EGFR mutation details and clearly documents why other EGFR inhibitors failed or aren't appropriate. The key is matching your clinical story to Cigna's specific coverage criteria rather than submitting generic prior auth forms.

Appeals Process in Virginia

If Cigna denies your Tagrisso prior authorization, Virginia provides strong appeal rights through the State Corporation Commission's Bureau of Insurance.

Internal Appeals with Cigna

  • First-level internal appeal: 180 days from denial notice
  • Timeline: Standard review within 30 days, expedited within 72 hours
  • How to file: Call Cigna member services or submit through provider portal
  • Required documents: Denial letter, additional clinical evidence, prescriber statement

Virginia External Review Process

After exhausting internal appeals, Virginia law provides independent external review:

Eligibility: Final adverse determination based on medical necessity
Deadline: 120 days from final internal denial notice
How to file: Submit Form 216-A to Virginia Bureau of Insurance
Timeline: 45 days for standard review, 72 hours for expedited
Success factors: Include oncology specialist recommendations and peer-reviewed evidence

Virginia Bureau of Insurance Contact: State Corporation Commission
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
Phone: 1-877-310-6560
External Review Forms

Note: Virginia allows expedited external review for cancer treatment denials without exhausting internal appeals in urgent situations.

Cost Assistance and Bridge Options

While navigating the approval process, several programs can help bridge coverage gaps:

AstraZeneca Patient Assistance Programs

  • Tagrisso Co-Pay Savings Program: Reduces copay to $0 for commercially insured patients
  • Enrollment: Call 844-275-2360 or visit MyAccess360.com
  • AZ&Me Program: Free medication for uninsured patients (income-based eligibility)

Temporary Supply Options

  • 90-day mail-order fills: Request through specialty pharmacy to reduce interruptions
  • Prior authorization bridge: Some plans provide temporary supply during PA review
  • Appeals continuation: Maintain current therapy during internal appeal process

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-based responses. Their platform helps patients and providers navigate complex prior authorization requirements and appeal processes more effectively.

When to Contact Virginia Regulators

Contact the Virginia Bureau of Insurance if you experience:

  • Unreasonable delays in prior authorization processing
  • Denial of medically necessary cancer treatment
  • Failure to follow Virginia external review procedures
  • Discrimination based on diagnosis or treatment cost

The Bureau's Managed Care Ombudsman can assist with HMO and managed care plan issues, providing informal resolution before formal appeals.

Frequently Asked Questions

How long does Cigna prior authorization take for Tagrisso in Virginia?
Standard requests are processed within 72 hours of receiving complete documentation. Urgent requests can be expedited within 24 hours with physician certification.

What if Tagrisso isn't on my Cigna formulary?
Request a formulary exception with clinical justification. Virginia law requires coverage of medically necessary treatments even if non-formulary, subject to appeal rights.

Can I get expedited review if my cancer is progressing?
Yes. Virginia allows expedited external review (72 hours) for urgent medical conditions. Your oncologist must certify that delays could jeopardize your health.

Does step therapy apply to Tagrisso in Virginia?
Cigna may require trial of other EGFR inhibitors first. However, step therapy exceptions are available if you've previously failed or are intolerant to preferred alternatives.

What happens if I change jobs during treatment?
Maintain continuous coverage through COBRA if possible. New plans may require new prior authorization, but Virginia prohibits discrimination against pre-existing conditions.

How often do I need to renew Tagrisso approval?
Cigna requires annual prior authorization renewal. Begin the renewal process 4-6 weeks before expiration to avoid treatment interruption.

Can I appeal to Virginia if I have a self-funded employer plan?
Self-funded plans may opt into Virginia's external review process. If not opted in, you may have federal external review rights through HHS. The Bureau of Insurance can help determine your options.

What documentation strengthens my appeal?
Include EGFR mutation testing results, treatment response data, peer-reviewed studies supporting osimertinib use, and detailed letters from your oncology team citing NCCN guidelines.

For additional support navigating insurance coverage challenges, Counterforce Health offers specialized assistance in converting insurance denials into successful approvals through targeted, evidence-based appeals tailored to specific payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies may vary by plan and change over time. For current Virginia insurance regulations and appeal procedures, contact the State Corporation Commission Bureau of Insurance directly.

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