By Counterforce Health Team in Tagrisso (osimertinib) —

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

Answer Box: Getting Tagrisso Covered by Cigna in Washington

Cigna covers Tagrisso (osimertinib) for EGFR-mutated NSCLC with prior authorization. First step today: Have your oncologist submit PA through Cigna's provider portal with EGFR mutation test results, staging, and treatment history. Standard decisions take 72 hours; expedited reviews 24 hours for urgent cases. If denied, you have 180 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO) process. Cigna's Tagrisso policy requires documented EGFR mutations and appropriate treatment setting.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process in Washington
  5. Cost-Saving Options
  6. When to Contact Washington Regulators
  7. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Tagrisso prescriptions Cigna PA Policy
EGFR Mutation Documented exon 19 deletion, L858R, or T790M FDA-approved test results
Specialty Pharmacy Must fill through Express Scripts/Accredo Cigna member portal
Step Therapy May require trial of other EGFR TKIs first Can be overridden with medical necessity
Quantity Limits 60 tablets per 30 days (80mg strength) Cigna quantity policy
Annual Renewal Required every 12 months Submit 4-6 weeks before expiration

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: Patient and oncology team
What you need:

  • EGFR mutation test results (FDA-approved test)
  • Pathology report with staging
  • Treatment history and prior EGFR TKI trials
  • Recent clinic notes showing performance status

2. Submit Prior Authorization

Who does it: Prescribing oncologist
How to submit: Cigna provider portal or fax
Timeline: Standard review 72 hours, expedited 24 hours
Mark as urgent if: Patient hospitalized or treatment delay could harm health

Tip: Request expedited review for any delay that could impact cancer progression or patient safety.

3. Specialty Pharmacy Setup

Who does it: Patient with pharmacy assistance
When: After PA approval
Process: Transfer prescription to Express Scripts/Accredo
Timeline: 2-3 business days for first fill

4. Monitor for Renewal

When to start: 4-6 weeks before current authorization expires
Required updates: Recent imaging, clinic notes showing response to therapy
Renewal frequency: Every 12 months typically

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit FDA-approved test results Molecular pathology report with specific mutation type
Wrong treatment setting Clarify adjuvant vs. metastatic indication Staging documents, surgical reports if adjuvant
Step therapy not met Request medical necessity override Prior TKI trial records, intolerance documentation
Insufficient clinical information Provide complete treatment history Comprehensive oncology notes, imaging reports
Quantity exceeded Justify dosing or request override Weight-based dosing rationale, drug interaction documentation

Clinician Corner: Medical Necessity Letter Checklist

When writing appeals, oncologists should include:

  • Problem statement: EGFR-mutated NSCLC diagnosis with ICD-10 codes
  • Prior treatments: Specific EGFR TKIs tried, duration, and reason for discontinuation
  • Clinical rationale: Why Tagrisso is appropriate per NCCN guidelines
  • Monitoring plan: Cardiac function, pulmonary toxicity surveillance
  • Treatment goals: Disease control, symptom management, quality of life

Appeals Process in Washington

Washington state provides strong consumer protections for insurance denials through a multi-level appeal process.

Internal Appeals (Required First Step)

  • Deadline: 180 days from denial notice
  • Response time: 30 days standard, 15 days for urgent cases
  • How to file: Written request to Cigna with denial letter and supporting documentation
  • Required documents: Original denial, medical records, physician attestation

External Review Through IRO

After exhausting internal appeals, Washington residents can request external review by an Independent Review Organization.

  • Deadline: 180 days from final internal denial
  • Cost: Free to patient
  • Process: Cigna assigns IRO from state-certified list
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Decision: Binding on Cigna if overturned
Note: Washington's external review process has helped many patients overturn specialty drug denials, especially when strong clinical evidence supports medical necessity.

How to Request External Review

  1. Contact Cigna member services to request external review form
  2. Submit completed form with all medical documentation
  3. IRO reviews case with appropriate medical specialists
  4. Receive written decision within timeline

For assistance, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

Cost-Saving Options

Tagrisso's list price exceeds $15,000 per month, but several programs can reduce costs:

AstraZeneca Patient Support

  • Co-pay savings: For commercial insurance patients (not Medicare/Medicaid)
  • Patient assistance program: Free drug for qualifying uninsured patients
  • Bridge therapy: Temporary supply while coverage is pending
  • Contact: 1-800-236-9933

Medicare Patients

  • 2025 Part D cap: $2,000 annual out-of-pocket maximum
  • Payment plan: Spread costs monthly through Medicare Prescription Payment Plan
  • Extra Help: Low-income subsidy program reduces or eliminates co-pays

Foundation Grants

  • Patient Access Network (PAN) Foundation
  • CancerCare Co-Payment Assistance
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Check current availability as funding opens and closes throughout the year.

When to Contact Washington Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Cigna doesn't respond to appeals within required timelines
  • You need help understanding your appeal rights
  • You believe Cigna violated state insurance laws
  • You need assistance with the external review process

Washington OIC Consumer Advocacy: 1-800-562-6900
Online complaint form: insurance.wa.gov

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Tagrisso in Washington? A: Standard reviews take 72 hours, expedited reviews 24 hours. Mark requests as urgent if treatment delays could impact patient safety.

Q: What if Tagrisso is non-formulary on my Cigna plan? A: Request a formulary exception with medical necessity documentation. Your oncologist must demonstrate why covered alternatives are inappropriate.

Q: Can I get expedited appeals in Washington? A: Yes, for urgent medical situations. Both internal appeals and external IRO reviews have expedited timelines (15 days internal, 72 hours external).

Q: Does step therapy apply if I've tried EGFR TKIs outside Washington? A: Yes, prior treatment history from any location counts. Provide documentation of previous TKI trials and outcomes.

Q: What happens if my Tagrisso authorization expires? A: Start renewal 4-6 weeks early. If it lapses, ask about bridge therapy from AstraZeneca while renewal is processed.

Q: Can Washington's external review overturn Cigna denials? A: Yes, IRO decisions are binding on Cigna. External review has helped many patients access specialty medications initially denied.

From Our Advocates

"We've seen many Tagrisso denials overturned in Washington when patients provide complete EGFR mutation documentation and clear evidence of appropriate treatment setting. The key is thorough documentation from the start and using Washington's strong external review process when needed. Don't give up after an initial denial - the appeals process works when you have the right clinical evidence."

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific denial basis and draft point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

When facing complex prior authorization challenges like Tagrisso coverage, having expert support can make the difference between approval and denial. Counterforce Health's system understands payer-specific workflows and produces letters that meet procedural requirements while tracking deadlines and required documentation.

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 about treatment decisions and your insurance plan for specific coverage details. Coverage policies and appeal processes may vary by plan type and can change over time.

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