By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by Cigna in Illinois: Complete Forms, Appeals Guide & State Resources

Answer Box: Getting Tavneos (Avacopan) Covered by Cigna in Illinois

Fastest Path to Approval: Submit prior authorization through CoverMyMeds or Accredo's electronic portal with complete ANCA-associated vasculitis documentation, including diagnosis confirmation, prior therapy failures, and specialist prescriber details. If denied, file internal appeal within 180 days, then external review through Illinois Department of Insurance within 4 months. Start today: Verify your plan covers specialty medications through Express Scripts/Accredo at 1-800-351-3606, then gather clinical records showing severe active GPA/MPA diagnosis and previous treatment attempts.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Electronic Submission Portals
  4. Specialty Pharmacy Setup
  5. Appeal Process: Internal & External
  6. Support Phone Numbers & Case Management
  7. Illinois Regulatory Resources
  8. Common Denial Reasons & Solutions
  9. Costs & Patient Assistance

1. Verify Your Plan & Find the Right Forms

Before starting your Tavneos (avacopan) approval process, confirm your Cigna plan includes specialty pharmacy benefits through Express Scripts and Accredo. Most Cigna commercial plans route specialty medications through this network.

What You Need to Verify:

  • Your plan includes specialty pharmacy coverage
  • Tavneos requires prior authorization (it typically does)
  • Whether step therapy requirements apply
  • Your current formulary tier for Tavneos

Call 1-800-244-6224 with your member ID to confirm these details, or log into your myCigna portal to review your prescription drug benefits.

2. Prior Authorization Forms & Requirements

Current Cigna PA Process (2024/2025)

Cigna requires electronic submission for most prior authorizations. The current process uses:

  • CoverMyMeds as the primary portal
  • Accredo Prescriber Portal for specialty medications
  • Evicore by Evernorth Pharmacy Drug Portal for Express Scripts coverage

Required Clinical Documentation

Your prescriber must include:

Patient Information:

  • Name, date of birth, Cigna member ID
  • Complete contact information

Clinical Justification:

  • Confirmed diagnosis of severe active ANCA-associated vasculitis (GPA or MPA)
  • ICD-10 codes for granulomatosis with polyangiitis or microscopic polyangiitis
  • ANCA test results (c-ANCA/PR3 or p-ANCA/MPO positive)
  • Current disease activity markers

Treatment History:

  • Previous therapies tried and failed or contraindicated
  • Documentation of intolerance to standard treatments
  • Rationale for adjunctive therapy approach

Prescriber Details:

  • Specialist credentials (rheumatology, nephrology, or pulmonology)
  • DEA number or TIN
  • Office contact information
Tip: Tavneos is approved only as adjunctive therapy with standard treatments like rituximab or cyclophosphamide plus glucocorticoids. Ensure your request clearly states this combination approach.

3. Electronic Submission Portals

Primary Submission Methods

CoverMyMeds (Recommended):

  1. Go to CoverMyMeds.com
  2. Search for "Cigna" and "Tavneos"
  3. Complete the generated form with all required clinical data
  4. Upload supporting medical records

Accredo Prescriber Portal:

  • Register at the Accredo prescriber portal
  • Upload medical records directly
  • Track prescription and PA status
  • Communicate with Accredo clinical teams

Alternative Submission:

  • Fax completed forms to the number listed on the PA form
  • Call 1-800-882-4462 for urgent submissions
  • Standard response time: 5 business days

4. Specialty Pharmacy Setup

Once approved, Tavneos will be dispensed through Accredo Specialty Pharmacy. Here's how to set up your account:

Patient Setup Steps

  1. Enrollment: Call 1-800-351-3606 after PA approval
  2. Insurance Verification: Provide your Cigna member ID
  3. Delivery Setup: Choose home delivery or pickup options
  4. Clinical Consultation: Schedule pharmacist consultation for medication education

Prescription Transfer

If you have an existing Tavneos prescription elsewhere:

  • Provide previous pharmacy information to Accredo
  • They'll handle the transfer process
  • Ensure no gaps in therapy during transition
Note: Tavneos requires liver function monitoring. Accredo will coordinate lab reminders and results tracking with your healthcare team.

5. Appeal Process: Internal & External

Internal Appeals with Cigna

First-Level Appeal:

  • Deadline: 180 days from denial date
  • Submission: Written appeal with supporting documentation
  • Timeline: Cigna must respond within 60 days
  • Required: Copy of denial letter, additional clinical evidence

Peer-to-Peer Review:

  • Request direct physician-to-physician discussion
  • Your prescriber speaks with Cigna medical director
  • Often resolves complex cases more effectively than written appeals

Illinois External Review Process

Illinois offers strong patient rights under the Health Carrier External Review Act:

Eligibility:

  • Must complete Cigna's internal appeal process first
  • Denial must involve medical judgment
  • File within 4 months of final internal denial

Process:

  1. Request Form: Contact Illinois Department of Insurance at (877) 527-9431
  2. Assignment: Independent Review Organization (IRO) assigned within 5 business days
  3. Review: Board-certified specialist reviews your case
  4. Decision: Standard review within 30 days, expedited within 72 hours
  5. Binding: Cigna must provide coverage if denial is overturned

Illinois DOI Contact:

6. Support Phone Numbers & Case Management

Key Contact Numbers

Service Phone Number Best For
Cigna Specialty Pharmacy 1-800-351-3606 Tavneos-specific questions, PA status
General Cigna Customer Service 1-800-244-6224 Benefits verification, general inquiries
Case Management Referral Fax: 1-866-730-1556 Complex medical cases
Home Delivery Pharmacy 1-800-835-3784 Non-specialty medications

What to Ask When You Call

For PA Status:

  • "What's the current status of my Tavneos prior authorization?"
  • "What additional documentation is needed?"
  • "Can you expedite this request due to medical urgency?"

For Appeals:

  • "I need to file an internal appeal for Tavneos denial"
  • "Can you connect me to the appeals department?"
  • "What's the deadline for my appeal submission?"

7. Illinois Regulatory Resources

State Consumer Assistance

Illinois Department of Insurance:

  • Consumer Hotline: (877) 527-9431
  • Services: Appeal guidance, external review forms, complaint filing
  • Website: IDOI Consumer Resources

Illinois Attorney General Health Care Bureau:

  • Helpline: (877) 305-5145
  • Services: Informal intervention with insurers, consumer advocacy
  • Best for: Complex cases needing additional support

External Review Timeline

Step Timeline Action Required
File Request Within 4 months of final denial Submit IDOI form
IRO Assignment 5 business days Automatic
Medical Review 30 days (standard) IRO reviews case
Decision Binding immediately Cigna must comply
Expedited Review 72 hours For urgent medical situations

8. Common Denial Reasons & Solutions

Typical Denial Scenarios

Denial Reason Solution Documentation Needed
"Not prescribed as adjunctive therapy" Clarify combination with standard therapy Treatment plan showing concurrent use with rituximab/cyclophosphamide
"Insufficient diagnosis documentation" Provide complete ANCA vasculitis workup ANCA test results, biopsy reports, imaging
"Non-specialist prescriber" Transfer to appropriate specialist Referral to rheumatology, nephrology, or pulmonology
"Step therapy not completed" Request medical exception Document contraindications or failures with preferred agents
"Quantity limit exceeded" Justify dosing requirements Clinical rationale for 30mg BID dosing

Medical Necessity Letter Essentials

Your prescriber's letter should include:

  1. Patient's specific diagnosis with ICD-10 codes
  2. Disease severity and current activity markers
  3. Previous treatment failures or contraindications
  4. Clinical rationale for Tavneos as adjunctive therapy
  5. Monitoring plan including liver function tests
  6. Treatment goals and expected outcomes

9. Costs & Patient Assistance

Financial Support Options

Amgen SupportPlus:

Foundation Assistance:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Estimated Costs:

  • Retail price: ~$17,000 per 30-day supply
  • Annual cost: $170,000-$210,000
  • Copay assistance can significantly reduce out-of-pocket costs
From Our Advocates: We've seen cases where initial denials for Tavneos were overturned when prescribers emphasized the drug's role in reducing steroid exposure and provided clear documentation of ANCA-associated vasculitis severity. The key is thorough clinical documentation and persistence through the appeal process.

Getting help with complex insurance appeals: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate prior authorization requirements by analyzing denial letters and crafting point-by-point rebuttals aligned with each payer's specific policies and procedures.

FAQ: Tavneos (Avacopan) Coverage with Cigna in Illinois

Q: How long does Cigna prior authorization take for Tavneos? A: Standard review takes up to 5 business days. Expedited reviews for urgent medical situations can be completed within 24 hours.

Q: What if Tavneos isn't on my Cigna formulary? A: You can request a formulary exception with clinical justification. This requires demonstrating medical necessity and why preferred alternatives aren't suitable.

Q: Can I get an expedited appeal in Illinois? A: Yes, both Cigna internal appeals and Illinois external reviews offer expedited pathways when delays could jeopardize your health.

Q: Does step therapy apply if I've tried treatments outside Illinois? A: Previous treatment history from any location counts toward step therapy requirements. Provide complete documentation of all prior therapies.

Q: What happens if my external review is approved? A: The decision is binding on Cigna. They must immediately provide coverage and cannot appeal the IRO's decision.

Q: How do I transfer my prescription to Accredo? A: Call 1-800-351-3606 after PA approval. Accredo will coordinate the transfer and ensure no gaps in therapy.

Sources & Further Reading

This guide provides educational information and should not replace professional medical or legal advice. For personalized assistance with your specific situation, consult your healthcare provider and contact the Illinois Department of Insurance consumer assistance programs listed above. Insurance policies and procedures may change; verify current requirements with your plan.

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