By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Cigna in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Taltz Covered by Cigna in Georgia

Cigna requires prior authorization for all Taltz (ixekizumab) prescriptions. Your fastest path to approval: have your prescriber document failure of at least one traditional systemic agent (methotrexate, cyclosporine, acitretin, or PUVA) for 3+ months, submit negative tuberculosis screening within 12 months, and include specific diagnosis codes. Standard approval takes 5 business days; expedited decisions in 72 hours. If denied, you have 180 days for internal appeal, then 60 days for Georgia external review through the Georgia Department of Insurance.

First step today: Contact your prescriber to initiate the prior authorization through Cigna's provider portal or call 1-800-882-4462.

Table of Contents

Policy Overview: How Cigna Manages Taltz Coverage

Cigna classifies Taltz (ixekizumab) as a Tier 4 specialty medication requiring prior authorization across all plan types—HMO, PPO, and Medicare Advantage. The medication is managed through Express Scripts/Accredo specialty pharmacy, Cigna's specialty drug partner.

Plan-Specific Considerations:

  • Commercial plans: Standard 5-day prior authorization timeline
  • Medicare Advantage: May have additional quantity limits or enhanced step therapy requirements
  • Individual marketplace plans: Follow commercial criteria with potential state-specific modifications
Note: Cigna's coverage policies apply uniformly across Georgia, but your specific plan documents may include additional restrictions. Always verify your plan's formulary status through the myCigna portal.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Formulary Status

  • Your prescriber checks Cigna's formulary to confirm Taltz tier placement
  • Timeline: Same day
  • Submit through: Cigna provider portal or call 1-800-882-4462

2. Complete Required Screening

  • Tuberculosis test (TST or IGRA) within 12 months
  • Document any contraindications to step therapy agents
  • Timeline: 1-2 weeks for lab results

3. Document Prior Treatment Failures

  • Minimum 3 months of traditional systemic therapy failure
  • Acceptable agents: methotrexate, cyclosporine, acitretin, or PUVA therapy
  • Include specific dates, dosages, and documented outcomes

4. Submit Prior Authorization

  • Prescriber submits through Cigna provider portal, CoverMyMeds, or fax
  • Include all required clinical documentation
  • Timeline: Standard 5 days, expedited 72 hours

5. Enroll with Accredo Specialty Pharmacy

  • Occurs after PA approval
  • Timeline: 1-2 days enrollment, 1-2 weeks for first shipment
  • Contact: 877-826-7657

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Prescriber submission Cigna PA Policy
Formulary Tier Tier 4 Specialty Verify through myCigna Express Scripts Formulary
Step Therapy 3+ months traditional systemic failure Drug names, dates, outcomes Cigna Coverage Policy
TB Screening TST or IGRA within 12 months Negative test results FDA Prescribing Information
Age Requirement ≥6 years for psoriasis Date of birth verification FDA Label
Specialty Pharmacy Accredo required Automatic enrollment post-approval Cigna Specialty Pharmacy

Step Therapy & Medical Exceptions

Required Prior Treatments by Indication:

Plaque Psoriasis:

  • At least one traditional systemic agent for minimum 3 months
  • Acceptable agents: methotrexate, cyclosporine, acitretin, PUVA therapy
  • Note: TNF inhibitors are not universally required before Taltz approval

Psoriatic Arthritis/Ankylosing Spondylitis:

  • Conventional DMARDs and NSAIDs must be documented as failed or contraindicated
  • Include specific medication names, dosages, duration, and reason for discontinuation

Medical Exception Pathways: If you cannot take required step therapy agents, your prescriber can request an exception by documenting:

  • FDA-label contraindications
  • Documented allergies or intolerances
  • Drug interactions with current medications
  • Medical conditions preventing use of step therapy agents
From our advocates: We've seen fastest approvals when prescribers include a brief narrative explaining not just what was tried, but specifically why each prior treatment was inadequate—whether due to lack of efficacy after adequate trial period, intolerable side effects, or medical contraindications. This clinical context helps reviewers understand the medical necessity.

Required Diagnostics and Screening

Tuberculosis Screening (Mandatory):

  • Acceptable tests: Tuberculin skin test (TST) or interferon-gamma release assay (IGRA/QuantiFERON)
  • Timing: Within 12 months of treatment initiation
  • Results required: Documented negative results
  • Chest X-rays: No longer routinely required

Clinical Documentation:

  • Confirmed diagnosis with appropriate ICD-10 codes
  • Disease severity assessment
  • Objective clinical measures supporting need for biologic therapy
  • Documentation of treatment goals

Lab Monitoring: While not required for initial approval, baseline labs are recommended per FDA labeling for ongoing monitoring during treatment.

Specialty Pharmacy Requirements

Accredo Enrollment Process: Taltz must be dispensed through Accredo specialty pharmacy for Cigna coverage. After prior authorization approval:

  1. Automatic referral from Cigna to Accredo (1-2 days)
  2. Patient contact from Accredo for enrollment and delivery preferences
  3. First shipment typically within 1-2 weeks
  4. Ongoing deliveries scheduled based on dosing frequency

Site of Care:

  • Self-administration: Medication shipped to patient's home
  • Provider administration: Shipped directly to prescriber's office
  • No retail pharmacy option for specialty tier medications

Contact Information:

  • Accredo: 877-826-7657 (Monday-Friday business hours)
  • Available services: 24/7 pharmacist support, injection training, refrigerated shipping

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient step therapy documentation Provide detailed prior treatment history Drug names, dates, specific outcomes, reason for discontinuation
Missing TB screening Submit negative test results TST or IGRA results within 12 months
Lack of diagnosis documentation Include specific ICD-10 codes Medical records confirming psoriasis, PsA, or AS diagnosis
"Not medically necessary" Submit medical necessity letter with guidelines American Academy of Dermatology guidelines, peer-reviewed studies
Quantity limit exceeded Request quantity limit override Clinical rationale for higher dosing frequency

Medical Necessity Letter Checklist for Prescribers:

  • Patient's specific diagnosis and ICD-10 codes
  • Disease severity and impact on daily functioning
  • Detailed prior treatment history with specific outcomes
  • Clinical rationale for Taltz specifically
  • Treatment goals and expected outcomes
  • References to published treatment guidelines

Appeals Process in Georgia

Internal Appeal (First Level):

  • Timeline: 180 days from initial denial to file
  • Decision timeframe: Standard 30 days, expedited 72 hours
  • How to file: Cigna member portal, phone, or written request
  • Required: Copy of denial letter, supporting clinical documentation

External Review (Georgia Department of Insurance):

  • Timeline: 60 days from final internal denial to file
  • Decision timeframe: 30 days standard, 72 hours expedited
  • Cost: Free to patients
  • Authority: Georgia Department of Insurance
  • Contact: 1-800-656-2298

Georgia External Review Process:

  1. Complete internal appeals first (required)
  2. Submit Georgia External Review Request form within 60 days
  3. Independent medical reviewers evaluate your case
  4. Decision is legally binding on Cigna
Tip: Georgia allows concurrent expedited external review during internal appeals if your medical situation is urgent and delays could jeopardize your health.

Costs and Patient Assistance

Typical Patient Costs:

  • Tier 4 specialty copay: Varies by plan (typically $50-$200+ per month)
  • Deductible: May apply before copay kicks in
  • Out-of-pocket maximum: Annual limit provides cost protection

Manufacturer Support:

  • Taltz Together Savings Program: Up to $25,000 annual assistance for eligible patients
  • Eligibility: Commercial insurance patients (not Medicare/Medicaid)
  • Application: Available through Lilly.com or prescriber office

Additional Resources:

  • Patient advocacy organizations for psoriasis/arthritis conditions
  • State pharmaceutical assistance programs
  • Foundation grants for specialty medications

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-based rebuttal strategies tailored to each payer's specific requirements. Our platform analyzes denial letters and plan policies to identify the exact criteria needed for approval, then generates targeted appeals with the right clinical evidence and procedural documentation.

FAQ: Taltz Coverage in Georgia

How long does Cigna prior authorization take for Taltz in Georgia? Standard prior authorization takes 5 business days. Expedited reviews for urgent medical situations are completed within 72 hours.

What if Taltz is non-formulary on my Cigna plan? You can request a formulary exception through your prescriber. Cigna reviews exception requests within 72 hours and must provide clinical rationale if denied.

Can I request expedited appeal in Georgia? Yes. Georgia allows expedited external review (72 hours) when standard timelines would jeopardize your health. Your treating physician must certify the urgency.

Does step therapy apply if I failed treatments outside Georgia? Yes. Prior treatment failures from any location count toward step therapy requirements, provided adequate documentation is available.

What happens if my Cigna appeal is denied? After exhausting internal appeals, you have 60 days to request external review through the Georgia Department of Insurance. This independent review is free and legally binding on Cigna.

How do I contact Accredo after approval? Accredo will contact you automatically after prior authorization approval. You can also call 877-826-7657 to initiate enrollment or check status.

Are there age restrictions for Taltz coverage? Cigna follows FDA labeling: patients must be ≥6 years old for pediatric psoriasis indications. Adult indications have no upper age limit.

What if I need Taltz for an off-label use? Off-label uses require additional clinical justification and supporting literature. Consider working with Counterforce Health to develop evidence-based appeals for non-FDA-approved indications.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions. For assistance with insurance appeals and coverage determination, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298 or visit oci.georgia.gov.

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