By Counterforce Health Team in Translarna (ataluren) —

How to Get Translarna (Ataluren) Covered by Cigna in Illinois: Forms, Appeals, and Approval Guide

Answer Box: Getting Translarna (Ataluren) Covered by Cigna in Illinois

Translarna (ataluren) requires prior authorization from Cigna/Express Scripts for DMD patients with confirmed nonsense mutations. Your neurologist must submit a PA request within 72 hours of prescribing, documenting genetic testing results, ambulatory status, and failed standard therapies. If denied, you have 180 days to file an internal appeal, followed by external review through the Illinois Department of Insurance within 4 months of final denial. Start by having your doctor check CignaForHCP.com for current PA criteria and submit via the provider portal or fax 800-753-2851.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Requirements
  3. Submission Portals & Methods
  4. Medical Necessity Criteria
  5. Appeals Process in Illinois
  6. Specialty Pharmacy Setup
  7. Support Contacts & Resources
  8. Common Denial Reasons & Solutions
  9. Illinois Regulatory Assistance
  10. FAQ

Verify Your Plan & Find the Right Forms

Before starting the Translarna (ataluren) approval process, confirm your specific Cigna plan details:

Check Your Coverage:

  • Log into myCigna.com or call the member services number on your insurance card
  • Navigate to "Prescription Drug Lists" to verify Translarna's formulary status
  • Look for prior authorization (PA), step therapy, or quantity limit requirements

Key Plan Information to Gather:

  • Policy number and group ID
  • Whether your plan is fully insured (subject to Illinois law) or self-funded ERISA
  • Current prescription drug list effective date
  • Specialty pharmacy requirements (typically Accredo for Cigna plans)
Note: Cigna manages most specialty drugs through Express Scripts/Accredo. Translarna, if covered, will likely require specialty pharmacy dispensing due to its high cost and limited distribution.

Prior Authorization Requirements

Translarna requires prior authorization from Cigna before coverage approval. The PA process involves your prescribing neurologist submitting clinical documentation to justify medical necessity.

Coverage at a Glance

Requirement Details Where to Find Timeline
PA Required Yes, all plans Cigna Formulary Submit before dispensing
Formulary Tier Typically Tier 4 (highest copay) myCigna.com drug list Check annually
Step Therapy Likely required (corticosteroids first) Provider portal criteria Document failures
Age Limits FDA approval: ages 2-5 years FDA Label Verify current status
Diagnosis DMD with nonsense mutation Genetic testing required Lab confirmation needed

Submission Portals & Methods

Provider Portal: CignaForHCP.com

  • Fastest processing (24-72 hours)
  • Real-time status updates
  • Secure document upload for labs, genetic testing, clinical notes

Express Scripts Portal: For utilization management

  • Call 800-753-2851 for verbal PA requests
  • Electronic submission through provider dashboard

Alternative Submission Methods

Fax: Submit PA forms and supporting documentation

  • Express Scripts: 800-753-2851 (verify current fax number)
  • Include cover sheet with patient ID, prescriber NPI, and urgency level

Phone: For urgent cases requiring expedited review

  • Cigna Customer Service: Number on member ID card
  • Express Scripts: 800-753-2851
  • Have all clinical documentation ready before calling

Medical Necessity Criteria

To approve Translarna (ataluren), Cigna typically requires documentation of:

Clinical Requirements

  1. Confirmed DMD Diagnosis
    • Genetic testing showing nonsense mutation in DMD gene
    • Specific stop codon mutations amenable to read-through therapy
    • Clinical presentation consistent with Duchenne muscular dystrophy
  2. Patient Characteristics
    • Age 2-5 years (current FDA approval parameters)
    • Ambulatory status (able to walk independently)
    • Baseline functional assessments (6-minute walk test ≥150 meters)
  3. Prior Therapy Documentation
    • Trial of corticosteroids (deflazacort, prednisone, or prednisolone)
    • Documentation of response, side effects, or contraindications
    • Other supportive care measures attempted

Clinician Corner: Medical Necessity Letter Checklist

When submitting your PA request, include these key elements:

✓ Patient demographics and insurance information
✓ Diagnosis: Duchenne muscular dystrophy with confirmed nonsense mutation
✓ Genetic testing results with specific mutation identified
✓ Current functional status (6MWT, North Star Ambulatory Assessment)
✓ Prior treatments tried and outcomes (corticosteroids, physical therapy)
✓ Clinical rationale for Translarna based on FDA labeling
✓ Dosing plan and monitoring schedule
✓ Literature support from clinical trials (ACT DMD study data)

Appeals Process in Illinois

If Cigna denies your Translarna PA request, Illinois provides strong patient protection through a two-level appeal process.

Step 1: Internal Appeal with Cigna

Deadline: 180 calendar days from denial notice
Timeline: Standard review within 30 days; expedited within 24-48 hours
How to Submit:

  • Use Cigna's "Request for Health Care Provider Payment Review" form
  • Include original denial letter, medical necessity documentation, and clinical evidence
  • Submit via provider portal, mail, or fax as specified in denial letter

What to Include:

  • Letter from neurologist explaining medical necessity
  • Genetic testing confirming nonsense mutation
  • Functional assessment data
  • Documentation of failed alternative therapies
  • Relevant literature supporting Translarna use

Step 2: Illinois External Review

Deadline: 4 months from final internal denial
Process: Independent Review Organization (IRO) evaluation
Timeline: Decision within 30 days (expedited: 72 hours)

How to File:

  • Contact Illinois Department of Insurance: (877) 850-4740
  • Submit external review request form (available on DOI website)
  • Include all denial letters, appeal documentation, and clinical records
Important: Illinois external review decisions are binding on Cigna. If the IRO approves coverage, Cigna must provide the treatment.

Specialty Pharmacy Setup

Once Translarna is approved, Cigna typically requires dispensing through Accredo Specialty Pharmacy.

Enrollment Process

  1. Automatic Transfer: If you have an existing specialty prescription with refills, it may transfer automatically to Accredo
  2. New Prescriptions: Your doctor sends the approved prescription directly to Accredo
  3. Account Setup: Accredo will contact you to establish delivery preferences and payment information

Managing Your Prescription

  • Refills: Order through myCigna.com, myCigna app, or by calling Accredo directly
  • Delivery: Standard shipping at no extra cost; expedited options available
  • Support: 24/7 access to specialty-trained pharmacists and nurses

Accredo Contact: Verify current phone number through your Cigna member portal or customer service

Support Contacts & Resources

Cigna Member Services

  • Phone: Number on your insurance ID card or 1-800-882-4462
  • Use for: Coverage verification, appeal status, general questions
  • Hours: Typically 24/7 for urgent matters

Provider Support

  • Cigna Provider Services: CignaForHCP.com
  • Express Scripts: 800-753-2851
  • Use for: PA submissions, peer-to-peer reviews, clinical criteria questions

Illinois Consumer Assistance

  • Department of Insurance Consumer Helpline: (877) 527-9431
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • Use for: Appeal guidance, complaint filing, regulatory assistance

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit detailed clinical rationale Genetic testing, functional assessments, specialist letter
"Experimental/investigational" Cite FDA approval status FDA labeling, clinical trial data, peer-reviewed literature
"Step therapy not completed" Document contraindications or failures Records of corticosteroid trials, side effects, ineffectiveness
"Age restrictions" Verify patient meets criteria Birth certificate, current age documentation
"Non-formulary drug" Request formulary exception Medical necessity letter, lack of alternatives documentation

From Our Advocates

"We've seen Translarna appeals succeed when families work closely with their neurologist to document the specific nonsense mutation and provide detailed functional assessments. The key is showing that standard DMD treatments have been tried and that the patient meets the narrow FDA criteria for this medication. Illinois' external review process has been particularly helpful for rare disease cases where initial denials don't properly consider the specialized nature of the treatment."

Illinois Regulatory Assistance

Illinois provides robust consumer protection for insurance denials:

Illinois Department of Insurance (IDOI)

  • Consumer Complaints: File online or call (877) 527-9431
  • External Review: (877) 850-4740
  • Website: insurance.illinois.gov

When to Contact IDOI:

  • Cigna misses appeal deadlines
  • Denial appears to violate Illinois insurance law
  • Need assistance understanding your rights
  • External review filing assistance

Illinois Attorney General

  • Health Care Bureau: (877) 305-5145
  • Can help with: Informal intervention with insurers, complaint mediation

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and clinicians navigate complex prior authorization requirements and draft compelling medical necessity letters that align with payer-specific criteria, particularly for rare disease medications like Translarna.

FAQ

How long does Cigna PA take for Translarna in Illinois? Standard review: 72 hours. Expedited review (if urgent): 24 hours. Electronic submissions through the provider portal are typically fastest.

What if Translarna is non-formulary on my Cigna plan? Request a formulary exception through your doctor. Document medical necessity and lack of suitable alternatives. Non-formulary appeals follow the same internal/external review process.

Can I request an expedited appeal if denied? Yes, if a delay would seriously jeopardize your health or during ongoing treatment. Contact Cigna immediately and specify the urgent nature of your request.

Does step therapy apply if I've tried corticosteroids outside Illinois? Yes, document all prior therapies regardless of where they were tried. Provide medical records showing dates, dosages, and outcomes of previous treatments.

What happens if my Cigna plan is through my employer? Employer-sponsored plans may be self-funded ERISA plans with different appeal rights. Check your denial letter for specific appeal instructions and deadlines.

How much does Translarna cost with Cigna coverage? Costs vary by plan. Translarna is typically a Tier 4 specialty drug with high copays. Check your plan's specialty drug copay structure and investigate manufacturer assistance programs.

Can I appeal a Cigna denial if I live in Illinois but work in another state? If your plan is issued in Illinois, you have Illinois appeal rights. If issued elsewhere, follow that state's procedures. Check your insurance card for the issuing state.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage decisions are made by your insurer based on your individual plan terms and clinical circumstances.

For personalized assistance with Translarna appeals and prior authorization requirements, Counterforce Health provides specialized support for patients navigating complex insurance approval processes for rare disease medications.

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