By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Cigna in Washington: Prior Authorization Forms, Appeal Process, and Coding Requirements

Quick Answer: Cigna requires prior authorization for Taltz (ixekizumab) in Washington, typically mandating documented failure of a TNF inhibitor first. Submit PA requests via CoverMyMeds or Cigna's provider portal with complete medical records. If denied, you have 180 days for internal appeals, then can request external review through Washington's Office of the Insurance Commissioner within 60 days. Success rates for specialty drug appeals range 35-60% with proper documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all indications Complete PA form via portal/fax
Step Therapy TNF inhibitor failure typically required Treatment history with dates, outcomes
Diagnosis FDA-approved conditions only ICD-10 codes: L40.0 (psoriasis), M45 (AS), M07 (PsA)
Prescriber Specialist consultation often required Rheumatologist or dermatologist notes
Age Requirements ≥6 years (psoriasis), ≥18 years (arthritis) Birth date verification
TB Screening Negative results required Lab reports, chest X-ray

Source: Cigna Taltz Prior Authorization Policy

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Formulary Status

  • Log into Cigna's provider portal or call provider services
  • Confirm Taltz is on formulary (typically specialty tier)
  • Check if patient's plan requires specialty pharmacy fulfillment

2. Gather Required Documentation

  • Complete diagnosis workup with appropriate ICD-10 codes
  • Document prior therapy failures (especially TNF inhibitors)
  • Obtain negative TB screening results
  • Prepare specialist consultation notes

3. Submit Prior Authorization

  • Use CoverMyMeds, Cigna provider portal, or fax to 866-873-8279
  • Include all supporting clinical documentation
  • Typical decision timeframe: 72 hours for standard requests

4. Follow Up and Track Status

  • Check portal for updates within 5-7 days
  • Request peer-to-peer review if initial denial
  • Prepare appeal documentation if needed
From our advocates: We've seen the strongest Taltz approvals include detailed documentation of why TNF inhibitors failed—not just "patient didn't respond," but specific measures like PASI scores before/after treatment, joint counts, or quality of life impacts. This clinical detail often makes the difference between approval and denial.

Medical Necessity Documentation

Essential Clinical Elements

For Plaque Psoriasis:

  • PASI score or BSA involvement demonstrating moderate-to-severe disease
  • Documentation of candidacy for systemic therapy or phototherapy
  • Trial of at least one traditional systemic agent (methotrexate, cyclosporine)
  • Current disease severity and impact on quality of life

For Psoriatic Arthritis:

  • Active disease documentation with joint counts, morning stiffness duration
  • Rheumatologist consultation or co-management
  • Failed therapy with conventional DMARDs where appropriate
  • Objective measures of inflammation (CRP, ESR)

For Ankylosing Spondylitis:

  • Confirmed diagnosis with imaging findings
  • Active disease with objective signs of inflammation
  • Failed trial of ≥2 NSAIDs at maximum tolerated doses for ≥4 weeks each
  • Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores if available

Step Therapy Documentation

Cigna typically requires documented failure or intolerance of at least one TNF inhibitor. Include:

  • Specific TNF inhibitor tried (Humira, Enbrel, Remicade, etc.)
  • Duration of therapy (usually requires adequate trial of 3+ months)
  • Reason for discontinuation with specific details
  • Clinical measures showing inadequate response or adverse events

Source: Cigna Step Therapy Policy

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Insufficient step therapy Document TNF inhibitor trial/failure Treatment dates, outcomes, adverse events
Lack of specialist involvement Obtain consultation Rheumatology or dermatology notes
Missing TB screening Complete infectious disease workup Negative TB test, chest X-ray
Non-formulary status Request formulary exception Medical necessity letter, cost comparison
Quantity limits exceeded Justify dosing regimen FDA labeling, clinical guidelines
Diagnosis not covered Verify ICD-10 coding Updated diagnostic documentation

Appeals Process in Washington

Washington state provides robust consumer protections for insurance denials through a two-tiered system.

Internal Appeals with Cigna

Timeline: 180 days from denial date to file Process:

  1. Submit completed appeal form with supporting documentation
  2. Include updated medical records and specialist letters
  3. Request peer-to-peer review between prescriber and Cigna medical director
  4. Decision required within 30 days (72 hours if expedited)

External Review (IRO Process)

If Cigna upholds the denial after internal appeals, Washington residents can request an Independent Review Organization (IRO) evaluation.

Key Details:

  • File within: 60 days of final Cigna denial
  • Process: Washington's Office of the Insurance Commissioner assigns certified IRO
  • Timeline: 20 days for standard review, 72 hours if expedited
  • Outcome: Binding decision on Cigna if overturned

Success Rates: National data suggests 35-60% overturn rates for specialty drug appeals with comprehensive medical necessity documentation.

To Initiate External Review:

  • Call Washington OIC Consumer Advocacy line: 1-800-562-6900
  • Submit request through OIC website or directly to Cigna
  • Provide all relevant medical records and treatment history

Source: Washington State Appeals Guide

Billing and Coding Essentials

HCPCS J-Codes and Unit Calculations

Primary Codes:

  • J3490: Unclassified drugs
  • J3590: Unclassified biologics

Critical Unit Conversion:

  • Taltz 80 mg prefilled syringe = 80 billing units (not 1 unit)
  • Always bill total milligrams as units to avoid underbilling
  • Double-check dose calculations before claim submission

ICD-10 Diagnostic Codes

Condition ICD-10 Code Documentation Requirements
Plaque Psoriasis L40.0 PASI score, BSA involvement
Psoriatic Arthritis M07.* Joint involvement, specialist notes
Ankylosing Spondylitis M45 Imaging confirmation, BASDAI scores
Non-radiographic Axial SpA M46.8 MRI findings, inflammatory markers

Common Billing Errors to Avoid

  • Unit conversion mistakes: Always use total mg as billing units
  • Missing prior authorization: Verify PA approval before dispensing
  • Incorrect modifiers: Use only when specifically required by policy
  • Specialty pharmacy requirements: Ensure fulfillment through approved network
  • Quantity limit violations: Respect maintenance dosing limits (typically 2 syringes per 28 days)

Patient Support Programs

Manufacturer Assistance

  • Taltz Savings Card: May reduce copays for eligible commercially insured patients
  • Lilly Cares Foundation: Patient assistance program for uninsured/underinsured
  • Information: Visit Taltz.com or call 1-844-825-8966

State and Federal Resources

  • Washington Apple Health (Medicaid): Coverage through state Medicaid program
  • Medicare Extra Help: Low-income subsidy for Part D beneficiaries
  • 340B Program: Discounted pricing at federally qualified health centers

Getting complex prior authorizations approved requires expertise in payer policies, medical necessity documentation, and appeals processes. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Frequently Asked Questions

How long does Cigna prior authorization take for Taltz? Standard PA decisions are typically rendered within 72 hours of submission. Expedited requests for urgent medical situations may be processed faster.

What if Taltz isn't on my Cigna formulary? You can request a formulary exception by submitting a medical necessity letter explaining why covered alternatives aren't appropriate for your condition.

Can I appeal if step therapy requirements seem inappropriate? Yes, clinical exceptions to step therapy can be granted with documentation of contraindications, previous intolerance, or urgent medical need.

Does Washington state law help with Cigna appeals? Washington provides strong consumer protections including binding external review through Independent Review Organizations (IROs) if internal appeals fail.

What documentation is most important for approval? Complete treatment history showing TNF inhibitor failure, specialist consultation notes, current disease severity measures, and negative TB screening typically carry the most weight.

How much does Taltz cost with Cigna coverage? Costs vary by plan, but Taltz is typically placed on specialty tiers with higher copays. Patient assistance programs may help reduce out-of-pocket expenses.

Can I get expedited review in Washington? Yes, if your health could be seriously jeopardized by delay, both Cigna internal appeals and Washington IRO external reviews offer expedited timelines (72 hours).

What happens if the IRO overturns Cigna's denial? The decision is binding on Cigna, and they must provide coverage for Taltz as determined by the independent medical experts.

Sources & Further Reading

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 the most current coverage policies and requirements. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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