By Counterforce Health Team in Trikafta / Kaftrio (elexacaftor/tezacaftor/ivacaftor) —

How to Get Trikafta Covered by Cigna in Ohio: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Trikafta Covered by Cigna in Ohio

Cigna covers Trikafta (elexacaftor/tezacaftor/ivacaftor) for eligible cystic fibrosis patients in Ohio with prior authorization. You need: genetic testing confirming at least one F508del or responsive CFTR mutation, age ≥2 years, and a CF specialist's prescription. Submit PA through Cigna's provider portal or via Accredo specialty pharmacy. If denied, you have 180 days for internal appeals, then external review through Ohio's Department of Insurance. First step today: Confirm your CFTR mutation status and contact your CF center to initiate the PA process.

Table of Contents

Plan Types & Coverage Differences

Cigna's HMO, PPO, and EPO plans in Ohio all cover Trikafta, but with different network and referral requirements:

Plan Type Pulmonologist Access Specialty Pharmacy Network Flexibility
HMO PCP referral usually required In-network only (Accredo) Most restrictive
PPO Direct access, no referral In/out-network options Most flexible
EPO Direct access, no referral In-network only Moderate
Tip: If you need regular CF specialist visits, PPO or EPO plans eliminate referral delays. However, all plan types require using Cigna's preferred specialty pharmacy network for Trikafta.

Formulary Status & Tiers

Trikafta appears on Cigna's 2024 formularies as a specialty drug with specific restrictions:

  • Formulary Status: Covered (Tier 1 specialty or preferred brand)
  • Restrictions: Prior Authorization (PA) + Quantity Limits (QL)
  • Standard Quantity: 84 tablets per 28 days
  • Alternatives: Other CFTR modulators based on genotype (Kalydeco, Orkambi, Symdeko)

The notation "PA; QL (84/28); NDS" indicates prior authorization required, quantity limit of 84 tablets per 28-day supply, and non-discrimination status.

Prior Authorization Requirements

Cigna's coverage policy requires all of the following for Trikafta approval:

Medical Necessity Criteria

✅ FDA-approved indication: Cystic fibrosis treatment
✅ Age requirement: Patient ≥2 years old
✅ Genetic requirement: At least one F508del mutation or another responsive CFTR mutation
✅ Prescriber requirement: CF specialist or consultation with CF specialist
✅ Clinical documentation: Diagnosis confirmation, baseline labs, pulmonary function tests

Required Documentation

  • Genetic testing report showing eligible CFTR mutations
  • CF specialist attestation letter
  • Recent clinic notes with ICD-10 diagnosis code
  • Baseline liver function tests (LFTs)
  • Pulmonary function test results
  • Prior therapy history (if applicable)
Clinician Corner: Your medical necessity letter should reference the patient's specific CFTR mutations, current clinical status, anticipated benefits, and your credentials as a CF specialist. Include baseline FEV1 and any recent pulmonary exacerbations to strengthen the case.

Step-by-Step: Fastest Path to Approval

1. Confirm Eligibility (Patient/Family)

What: Verify CFTR genetic testing shows F508del or responsive mutation
Timeline: Same day
Source: Review genetic test results from CF center

2. Schedule CF Specialist Visit (Patient/Family)

What: Ensure prescription comes from qualified CF specialist
Timeline: 1-2 weeks
Who: Board-certified pulmonologist with CF expertise

3. Complete PA Documentation (CF Specialist)

What: Submit Cigna's PA form with supporting records
How: Cigna provider portal or fax
Timeline: Submit within 24-48 hours of patient visit

4. Coordinate with Accredo (Patient/Family)

What: Enroll with Cigna's specialty pharmacy partner
Contact: 1-844-516-3319 (Trikafta dedicated line)
Timeline: 2-3 business days for setup

5. PA Review Period (Cigna)

What: Cigna medical review of complete submission
Timeline: 5 business days for standard review
Expedited: 72 hours if medically urgent

6. Approval & Dispensing (Accredo)

What: First shipment coordination and patient education
Timeline: 3-5 business days after approval
Delivery: Temperature-controlled shipping to patient

7. Ongoing Management (Patient/CF Team)

What: Annual renewals, monitoring, refill management
Requirements: Updated clinical assessments, continued specialist oversight

Specialty Pharmacy Setup

Cigna requires Trikafta dispensing through Accredo specialty pharmacy. The enrollment process involves:

Patient Responsibilities:

  • Respond to Accredo's initial contact call
  • Provide insurance and shipping information
  • Register for online account management
  • Schedule delivery appointments

Prescriber Requirements:

  • Complete Accredo enrollment form
  • Provide clinical documentation
  • Coordinate PA submission
  • Maintain ongoing monitoring protocols

Key Contacts:

  • Accredo Trikafta line: 1-844-516-3319
  • General patient intake: 877-826-7657
  • Online portal: myaccredopatients.com

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic testing Submit complete CFTR mutation report Lab report with specific mutations listed
Non-specialist prescriber Get CF specialist consultation/prescription Specialist credentials and attestation
Incomplete age verification Provide birth certificate or medical records Official age documentation
Missing baseline labs Submit recent liver function tests LFTs within 30 days of PA request
Quantity limit exceeded Justify higher dose medically Clinical rationale for increased quantity
Note: The most common denial reason is incomplete genetic documentation. Ensure your CFTR mutation report explicitly lists the specific mutations, not just "CF mutations detected."

Appeals Process in Ohio

If Cigna denies your Trikafta PA, Ohio provides a structured appeals pathway:

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice
  • Submission: Cigna member portal, phone, or mail
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Requirements: Original denial letter, updated clinical evidence, specialist support

Internal Appeals (Second Level)

  • Automatic: If first-level appeal is denied
  • Timeline: Additional 30 days
  • Review: Different medical reviewer than first level

External Review (Ohio Department of Insurance)

  • Eligibility: After completing internal appeals
  • Deadline: 180 days from final internal denial
  • Process: Ohio Department of Insurance assigns Independent Review Organization (IRO)
  • Timeline: 30 days for standard, 72 hours for expedited
  • Binding: IRO decision is final and binding on Cigna

Ohio External Review Process:

  1. Request form filed with Cigna (who forwards to ODI)
  2. ODI assigns certified IRO with CF expertise
  3. All records submitted to IRO for independent review
  4. IRO issues binding determination
  5. If overturned, Cigna must provide coverage

For assistance with Ohio appeals, contact:

  • Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • UHCAN Ohio (advocacy group): Provides consumer assistance
  • CF Foundation Compass: CF-specific insurance help

Cost-Share Information

Trikafta's annual list price exceeds $300,000, making cost-sharing a significant concern. Typical Cigna specialty drug cost-sharing includes:

Deductible: May apply before coverage begins
Coinsurance: Often 10-40% for specialty tiers
Copay: Fixed amount (varies by plan)
Out-of-pocket maximum: Annual limit on patient costs

Financial Assistance Options:

  • Vertex Patient Services: Manufacturer copay assistance program
  • CF Foundation Compass: Insurance navigation and emergency assistance
  • Patient Advocate Foundation: Copay relief programs
  • State pharmaceutical assistance: Ohio programs for eligible patients
From Our Advocates: "We've seen families reduce their Trikafta costs from over $1,000/month to under $50 by combining manufacturer copay cards with foundation grants. The key is applying for assistance programs before you need them—some have waiting periods or limited funding."

When to Escalate

Consider escalating to Ohio regulators if:

  • Cigna delays PA decisions beyond required timeframes
  • Appeals are improperly denied without medical review
  • External review requests are blocked inappropriately
  • Coverage is terminated without proper notice

Ohio Department of Insurance Complaint Process:

  • File online at insurance.ohio.gov
  • Include all denial letters, appeal submissions, and correspondence
  • ODI investigates and can order compliance

Federal Options:

  • CMS complaints for Medicare Advantage plans
  • Department of Labor for employer-sponsored ERISA plans
  • State attorney general for broader insurance practices

FAQ

How long does Cigna's PA process take in Ohio?
Standard PA decisions are required within 5 business days of receiving complete documentation. Expedited reviews (for urgent medical situations) must be completed within 72 hours.

What if Trikafta is non-formulary on my specific plan?
Request a formulary exception through Cigna's appeals process. Provide clinical documentation showing medical necessity and lack of suitable formulary alternatives.

Can I request an expedited appeal in Ohio?
Yes, if waiting for standard appeal timelines would seriously jeopardize your health. Both internal and external appeals have expedited pathways with 72-hour decision requirements.

Does step therapy apply if I've tried other CFTR modulators outside Ohio?
Prior therapy documentation from any location should satisfy step therapy requirements. Ensure your CF specialist includes this history in the PA request.

What happens if I move to Ohio with existing Trikafta coverage?
Contact Cigna member services immediately to ensure continuity of coverage. Ohio law provides transition periods for ongoing specialty drug therapy.

How often do I need PA renewal for Trikafta?
Typically annually, though some plans may require more frequent reviews. Your CF specialist will need to document continued clinical benefit and medical necessity.

Getting the right support for your Trikafta coverage can make all the difference. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial reasons and crafting evidence-backed responses that align with your plan's own policies. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and build stronger cases for coverage approval.

When facing a Trikafta denial from Cigna, having the right documentation and appeal strategy is crucial. Counterforce Health can help identify the specific denial basis—whether it's PA criteria, step therapy, or medical necessity—and draft targeted rebuttals using the clinical evidence and policy language that payers expect to see.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. Coverage policies and requirements may change; verify current information with official sources.

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