By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (Pexidartinib) Covered by Cigna in New York: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Turalio Covered by Cigna in New York

To get Turalio (pexidartinib) covered by Cigna in New York, you'll need prior authorization with specific TGCT documentation. First, confirm your prescriber is REMS-certified and submit a complete PA including: pathology confirming TGCT, imaging showing disease extent, surgical consultation stating surgery would cause "severe morbidity or functional limitations," and baseline liver tests. If denied, New York offers strong external appeal rights through the Department of Financial Services within 4 months of Cigna's final denial. Most approvals come through within 3-14 days when documentation is complete.

Start today: Log into myCigna to check Turalio's formulary status and contact your prescriber about REMS enrollment.

Table of Contents

  1. Understanding Cigna's Turalio Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. New York Appeals Process
  5. Medical Necessity Documentation
  6. REMS Requirements Explained
  7. Appeal Templates & Scripts
  8. When to Escalate
  9. FAQ

Understanding Cigna's Turalio Requirements

Cigna treats Turalio as a specialty oncology drug requiring prior authorization for all members. The medication must typically be dispensed through Accredo Specialty Pharmacy due to REMS requirements.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cigna plans Cigna PA Policy
REMS Enrollment Mandatory safety program Turalio REMS Portal
Specialty Pharmacy Must use Accredo Check your plan documents
Approval Duration Typically 12 months Cigna policy documents
Internal Appeal Window 180 days in New York New York insurance law

Step-by-Step: Fastest Path to Approval

1. Check Formulary Status (Patient)

  • Log into myCigna
  • Search "Turalio" or "pexidartinib"
  • Note any PA, QL (quantity limit), or specialty pharmacy requirements
  • Timeline: 5 minutes

2. REMS Enrollment (Prescriber + Patient)

  • Prescriber registers at Turalio REMS
  • Complete prescriber training and knowledge assessment
  • Patient enrollment form must be signed
  • Timeline: 1-3 business days

3. Gather Required Documentation (Clinic)

Essential documents for PA submission:

  • Pathology report confirming TGCT diagnosis
  • MRI/imaging showing disease extent and location
  • Surgical consultation explicitly stating surgery would cause "severe morbidity or functional limitations"
  • Baseline liver function tests (ALT, AST, bilirubin)
  • Office notes documenting symptoms and functional limitations

4. Submit Prior Authorization (Prescriber)

  • Use Cigna provider portal or designated PA system
  • Include all documentation from step 3
  • Confirm REMS enrollment status
  • Request expedited review if clinically urgent
  • Timeline: Standard review 3-14 days, expedited 24 hours

5. Follow Up and Track (Patient + Clinic)

  • Monitor PA status through provider portal
  • Respond quickly to any requests for additional information
  • Coordinate with Accredo for prescription fulfillment once approved
Tip: According to Counterforce Health, the most common cause of delays is incomplete surgical documentation. Ensure your surgeon's note explicitly uses FDA label language about "severe morbidity or functional limitations."

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing TGCT diagnosis Submit pathology report and imaging Biopsy results, MRI report with ICD-10 M12.2
Surgery not addressed Get explicit surgical consultation Surgeon note stating "severe morbidity" risk
REMS not enrolled Complete enrollment process REMS confirmation for prescriber and patient
Insufficient functional documentation Document specific limitations ADL impact, work restrictions, pain scores
Missing baseline labs Submit required safety labs LFTs, especially ALT/AST/bilirubin

New York Appeals Process

New York offers some of the strongest patient appeal rights in the nation through the Department of Financial Services (DFS).

Internal Appeals with Cigna

Level 1 Internal Appeal

  • Deadline: 180 days from denial notice
  • Decision timeline: 30 days (72 hours if expedited)
  • How to file: Cigna member portal or written appeal
  • What to include: Complete appeal letter, all medical records, denial notice

Level 2 Internal Appeal (if available)

  • Deadline: 60 days from Level 1 denial
  • Request peer-to-peer: Ask for specialist-to-specialist review
  • Decision timeline: 30 days standard

External Review Through NY DFS

After exhausting Cigna's internal appeals, you can request binding external review:

  • Deadline: 4 months from Cigna's final adverse determination
  • Cost: Maximum $25 (refunded if you win, waived for financial hardship)
  • Timeline: 30 days standard, 72 hours expedited, 24 hours for urgent drug appeals
  • Success rate: Approximately 55-61% for well-documented specialty drug appeals

How to file external appeal:

  1. Download External Appeal Application
  2. Complete consumer and physician sections
  3. Attach all Cigna denial letters and supporting medical records
  4. Submit online via DFS portal, fax, or mail
Note: External review decisions are binding on Cigna. If approved, they must cover Turalio and refund your appeal fee.

Medical Necessity Documentation

Core Elements for TGCT Medical Necessity

Your medical necessity letter should address these key points:

Confirmed Diagnosis

  • Pathology report with TGCT/PVNS confirmation
  • Imaging showing disease extent and symptomatic impact
  • Appropriate ICD-10 coding (typically M12.2 for TGCT)

Surgical Inappropriateness Use exact FDA language: "not amenable to improvement with surgery" due to risk of "severe morbidity or functional limitations." Document:

  • Diffuse disease involving multiple compartments
  • High risk of nerve damage, joint destruction, or amputation
  • History of failed prior surgeries with recurrence
  • Patient-specific surgical contraindications

Functional Impact Quantify limitations with specific examples:

  • "Cannot walk more than 100 feet without severe pain"
  • "Unable to climb stairs or perform overhead activities"
  • "Misses work 3+ days per month due to TGCT symptoms"
  • "Requires assistive devices for mobility"

Sample Medical Necessity Language

"Based on MRI findings showing diffuse TGCT involving multiple compartments of the knee joint and consultation with orthopedic oncology, surgical intervention would pose unacceptable risk of severe functional limitations including potential need for amputation or joint fusion. The patient experiences constant pain rated 8/10 with activity, cannot perform essential job duties, and has failed conservative management including NSAIDs, bracing, and physical therapy."

REMS Requirements Explained

Turalio carries a boxed warning for serious liver injury, requiring enrollment in the TURALIO REMS program.

Who Must Enroll

Prescribers:

  • Complete REMS training and knowledge assessment
  • Submit prescriber enrollment form
  • Enroll each patient individually

Patients:

  • Sign patient enrollment form and attestation
  • Undergo baseline liver function testing

Pharmacies:

  • Designate authorized representative
  • Complete pharmacy enrollment
  • Verify REMS status before each dispense

Monitoring Requirements

  • Baseline: Liver tests before starting treatment
  • Weeks 1-8: Weekly liver function tests
  • Weeks 9-12: Every 2 weeks
  • Ongoing: Every 3 months while on treatment

Contact for REMS support: 1-833-TURALIO (1-833-887-2546)

Appeal Templates & Scripts

Patient Phone Script for Cigna

"Hi, I'm calling about a prior authorization denial for Turalio (pexidartinib) for tenosynovial giant cell tumor. My member ID is [ID number]. I'd like to understand the specific reasons for denial and start the internal appeal process. Can you please connect me with someone who can help with specialty drug appeals?"

Medical Necessity Letter Template

Header: Patient information, provider details, Cigna member ID

Opening: "I am writing to request prior authorization for Turalio (pexidartinib) for [Patient Name], who has biopsy-confirmed tenosynovial giant cell tumor (TGCT) that is not amenable to surgical improvement."

Body sections:

  1. Diagnosis confirmation with pathology and imaging references
  2. Surgical consultation findings and contraindications
  3. Functional limitations and symptom burden
  4. Treatment history and failures
  5. REMS enrollment confirmation
  6. Clinical rationale tied to FDA indication

Closing: "This treatment is medically necessary and consistent with FDA labeling. I am available for peer-to-peer discussion and request expedited review given the patient's significant functional impairment."

When to Escalate

Contact New York Regulators

If Cigna fails to follow proper procedures or timelines:

New York Department of Financial Services

Community Health Advocates (Free Help)

  • Phone: 888-614-5400
  • Provides free assistance with insurance appeals in New York
  • Can help with both internal and external appeal processes

When to File Regulatory Complaints

  • Cigna misses appeal deadlines
  • Requests for additional information are unreasonable or repetitive
  • Denial reasons don't match medical evidence
  • Procedural violations in the appeal process

FAQ

How long does Cigna prior authorization take in New York? Standard PA review typically takes 3-14 days once complete documentation is received. Expedited reviews are decided within 24 hours when clinical urgency is documented.

What if Turalio is non-formulary on my plan? You can request a formulary exception with clinical justification. Cigna must decide within 72 hours for standard requests or 24 hours for expedited requests.

Can I get Turalio covered without trying surgery first? Yes, if your surgeon documents that surgery would cause "severe morbidity or functional limitations." This surgical consultation is required for approval.

Does REMS enrollment delay coverage? REMS enrollment typically takes 1-3 business days and can run concurrently with PA review. Ensure both prescriber and patient enrollment are complete before PA submission.

What happens if my external appeal is approved? Cigna must cover Turalio according to the external reviewer's decision. The decision is binding, and Cigna must also refund your $25 appeal fee.

How much does Turalio cost without insurance? Cash prices are approximately $23,850 for a typical 28-day supply, though actual costs vary by dose and strength. Manufacturer assistance programs may help eligible patients.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's requirements, significantly improving approval rates for complex cases like TGCT treatments.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance. Coverage policies and appeal procedures may vary by plan and can change over time.

Sources & Further Reading

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