By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by Cigna in Florida: Complete Appeals Guide with Forms and Timelines

Quick Answer: To get Tavneos (avacopan) covered by Cigna in Florida, you need prior authorization showing: (1) confirmed GPA or MPA diagnosis with positive ANCA, (2) prescription by a rheumatologist, nephrologist, or pulmonologist, and (3) use alongside standard immunosuppressive therapy. If denied, request a peer-to-peer review within 48 hours, then file an internal appeal within 180 days. Start with Cigna's prior authorization form and gather your ANCA results, specialist referral, and documentation of concurrent immunosuppressive treatment.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Tavneos prescriptions Cigna provider portal or fax submission Cigna PA Policy
Diagnosis GPA or MPA with positive ANCA Lab results showing anti-PR3 or anti-MPO FDA Label
Specialist Prescriber Rheumatologist, nephrologist, or pulmonologist Provider credentials and referral Cigna PA Criteria
Combination Therapy Must use with immunosuppressant (rituximab, cyclophosphamide, etc.) Treatment plan documentation ACR Guidelines
Age Requirement 18 years or older Patient demographics FDA Label
Internal Appeal Deadline 180 calendar days from denial Denial letter date stamp Florida Insurance Law

Step-by-Step: Fastest Path to Approval

1. Confirm Eligibility (Patient/Clinic)

  • Verify GPA or MPA diagnosis with positive ANCA (anti-PR3 or anti-MPO)
  • Ensure prescriber is a rheumatologist, nephrologist, or pulmonologist
  • Document concurrent use of immunosuppressive therapy
  • Timeline: 1-2 days for record gathering

2. Complete Prior Authorization (Clinic)

  • Submit Cigna's Tavneos PA form
  • Include ANCA lab results, specialist credentials, and treatment plan
  • Submit via Cigna provider portal or fax (verify current fax with Cigna)
  • Timeline: 30 days for standard review

3. If Denied: Request Peer-to-Peer Review (Clinic)

  • Call Cigna provider services within 48 hours of denial
  • Schedule discussion between prescriber and Cigna medical director
  • Prepare clinical rationale and guideline references
  • Timeline: 1-2 business days to schedule, immediate decision possible

4. File Internal Appeal if P2P Fails (Patient/Clinic)

  • Submit written appeal within 180 days of denial
  • Include medical necessity letter and supporting documentation
  • Use Cigna appeals portal
  • Timeline: 30 days for medical necessity appeals

5. Request External Review if Needed (Patient)

  • File with Florida Department of Financial Services within 4 months
  • Call 1-877-693-5236 or submit online
  • Timeline: 45 days for standard review, 72 hours for expedited

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not prescribed by specialist" Provide specialist credentials Board certification, referral letter
"Missing ANCA confirmation" Submit positive ANCA lab results Anti-PR3 or anti-MPO test results
"Not used with standard therapy" Document concurrent immunosuppressant use Treatment plan showing rituximab/cyclophosphamide
"Diagnosis not confirmed" Provide GPA/MPA diagnostic evidence Biopsy results, clinical criteria documentation
"Age requirement not met" Verify patient is 18+ Birth certificate or ID
"Experimental/investigational" Cite FDA approval and guidelines FDA approval letter, ACR recommendations

Appeals Playbook for Cigna in Florida

Internal Appeals Process

First-Level Internal Appeal

  • Deadline: 180 calendar days from denial notice
  • Timeline: 30 days for medical necessity decisions, 60 days for payment disputes
  • How to Submit: Cigna provider portal, fax, or mail
  • Required Documents: Completed appeal form, denial letter copy, medical necessity letter, clinical documentation

Expedited Appeals (Urgent Cases)

  • Timeline: 72 hours for decision
  • Eligibility: When delay could seriously jeopardize health
  • How to Request: Call Cigna and specify "expedited appeal" with clinical justification

External Review Process

If your internal appeal is denied, Florida law provides external review through an independent medical expert.

Eligibility Requirements:

  • Final denial from Cigna's internal appeal process
  • Medical necessity dispute (not just administrative issues)
  • Request filed within 4 months of final denial

How to Request:

  • Contact Florida Department of Financial Services: 1-877-693-5236
  • Submit via Florida DFS website
  • Include final denial letter, medical records, and external review form

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours for urgent cases
  • No cost to patient
  • Decision is binding on Cigna

Medical Necessity Letter Checklist

When writing your medical necessity letter for Tavneos (avacopan), include these essential elements:

Patient Information Section

  • Full name, date of birth, Cigna member ID
  • Diagnosis with ICD-10 codes (M31.30 for GPA, M31.7 for MPA)
  • ANCA test results (anti-PR3 or anti-MPO positive)

Clinical Rationale Section

  • Detailed disease history and current status
  • Prior treatments attempted and outcomes
  • Contraindications to standard steroid therapy (if applicable)
  • Expected benefits of Tavneos as steroid-sparing agent

Treatment Plan Section

  • Concurrent immunosuppressive therapy details
  • Dosing: 30 mg (three 10 mg capsules) twice daily with food
  • Monitoring plan including liver function tests
  • Duration of treatment (typically 6-12 months initially)

Evidence-Based Support

From Our Advocates: "We've seen the strongest approvals when specialists clearly document why standard steroid therapy alone isn't optimal for the patient—whether due to diabetes, osteoporosis, or other steroid-related complications. The key is connecting Tavneos's steroid-sparing benefit to the patient's specific clinical situation."

Peer-to-Peer Review Strategy

The peer-to-peer (P2P) review offers your best chance to reverse a denial quickly without formal appeals.

Scheduling Your P2P Call

  • Request within 48 hours of denial notification
  • Call Cigna provider services (number in denial letter)
  • Typically scheduled within 1-2 business days

Preparation Checklist

  • Review patient's complete medical history
  • Gather ANCA results and specialist credentials
  • Prepare 2-3 key clinical points about medical necessity
  • Have Cigna's PA criteria readily available

Key Talking Points

  1. Diagnosis Confirmation: "Patient has biopsy-confirmed GPA with positive anti-PR3 ANCA"
  2. Specialist Expertise: "As a board-certified rheumatologist, I'm following ACR guidelines for severe ANCA-associated vasculitis"
  3. Combination Therapy: "Tavneos is prescribed alongside rituximab per FDA labeling as adjunctive therapy"
  4. Medical Necessity: "Patient requires steroid-sparing approach due to [specific contraindication/complication]"

Documentation

  • Take detailed notes during the call
  • Request written confirmation of any approval
  • If denied, ask for specific reasons to address in formal appeal

Counterforce Health helps clinicians prepare for these conversations by analyzing denial patterns and crafting targeted rebuttals based on payer-specific criteria.

External Review Process in Florida

If Cigna upholds their denial through internal appeals, Florida's external review process provides a final avenue for coverage.

Filing Requirements

  • Deadline: 4 months from final internal denial
  • Cost: Free to patients
  • Contact: Florida Department of Financial Services at 1-877-693-5236

Required Documentation

  • Final denial letter from Cigna
  • All internal appeal correspondence
  • Complete medical records supporting Tavneos necessity
  • Physician statement of medical necessity

Review Process

Florida contracts with independent review organizations (often Maximus Federal) to conduct external reviews. The assigned medical expert:

  • Reviews all submitted documentation
  • Applies medical evidence standards
  • Issues binding decision within 45 days (72 hours if expedited)

Binding Outcomes

If the external reviewer overturns Cigna's denial:

  • Cigna must authorize coverage
  • Retroactive coverage may apply
  • Patient can proceed with treatment

Cost-Saving Options

While pursuing coverage approval, explore these cost assistance programs:

Manufacturer Support

  • Amgen SupportPlus: Patient assistance program for eligible uninsured/underinsured patients
  • Commercial Copay Card: May reduce out-of-pocket costs for insured patients
  • Contact: Visit tavneospro.com (verify with manufacturer)

Foundation Grants

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation (verify current programs)

Florida-Specific Resources

  • Florida Covering Kids & Families program
  • 211 Florida for local assistance programs

Frequently Asked Questions

Q: How long does Cigna prior authorization take for Tavneos in Florida? A: Standard prior authorization decisions are typically made within 30 days. Expedited reviews for urgent cases must be completed within 72 hours per Florida law.

Q: What if Tavneos isn't on Cigna's formulary? A: You can request a formulary exception by demonstrating medical necessity and lack of suitable alternatives. Use the same documentation process as prior authorization.

Q: Can I appeal if I'm on a Medicare Advantage plan through Cigna? A: Yes, but timelines may differ. Medicare Advantage appeals follow federal CMS guidelines, which may provide additional appeal levels beyond Florida's standard process.

Q: Does step therapy apply to Tavneos? A: Cigna typically requires documentation that standard immunosuppressive therapy is being used concurrently, but specific step therapy requirements vary by plan. Check your specific formulary.

Q: What counts as "severe active" ANCA-associated vasculitis? A: Generally requires at least one major organ involvement or multiple system involvement as measured by Birmingham Vasculitis Activity Score (BVAS). Your specialist should document specific clinical criteria.

Q: Can I request an expedited appeal in Florida? A: Yes, if delay in treatment could seriously jeopardize your health or ability to regain maximum function. Both Cigna and Florida's external review process offer expedited pathways.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes for high-cost specialty medications like Tavneos.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider about treatment decisions and verify current coverage requirements with your specific Cigna plan. For personalized assistance with insurance matters, contact Florida's Insurance Consumer Helpline at 1-877-693-5236.

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