By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (Pexidartinib) Covered by Cigna in Washington: Complete Timeline and Appeals Guide

Answer Box: Getting Turalio Approved by Cigna in Washington

Cigna requires prior authorization (PA) for Turalio (pexidartinib) to treat TGCT in Washington, with both prescriber and patient enrolled in the FDA-mandated REMS program before dispensing. Standard PA approval takes 3-14 days; expedited review within 24 hours for urgent cases.

Fastest approval path:

  1. Ensure prescriber is REMS-certified at TuralioREMS.com
  2. Submit complete PA with TGCT diagnosis, imaging, surgical assessment, and baseline liver tests
  3. Complete REMS enrollment (1-3 days) while PA processes

Start today: Contact your prescriber to confirm REMS certification and gather required documentation for PA submission.

Table of Contents

  1. What Affects Turalio Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window and Outcomes
  6. If Denied: Washington Appeals Process
  7. Renewal Cycles and Reauthorization
  8. Timeline Visual: Key Milestones
  9. Time-Saving Tips for Faster Approval
  10. Common Denial Reasons & Solutions
  11. FAQ

What Affects Turalio Approval Timing

Several factors influence how quickly Cigna approves Turalio (pexidartinib) in Washington:

Benefit Type and Plan Structure

  • Most Cigna plans manage specialty drugs through Express Scripts/Accredo, which typically processes PAs within 72 hours for standard requests
  • Expedited reviews are completed within 24 hours when clinical urgency is documented

Complexity of Criteria Turalio has specific approval requirements that can slow processing if incomplete:

  • Confirmed TGCT diagnosis with supporting pathology and imaging
  • Documentation that surgery isn't feasible or would cause severe morbidity
  • REMS program enrollment for both prescriber and patient
  • Baseline liver function tests due to hepatotoxicity risk

Documentation Completeness The most significant factor affecting approval speed is having all required documentation submitted initially. Counterforce Health helps patients and clinicians streamline this process by identifying denial reasons and preparing comprehensive appeals with proper evidence.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your PA, gather these required items:

Clinical Documentation:

  • Pathology report confirming TGCT diagnosis
  • MRI or imaging showing tumor extent and symptomatic impact
  • Surgical consultation notes explaining why surgery isn't appropriate
  • Clinical notes documenting functional limitations or severe morbidity
  • Baseline liver function tests (ALT, AST, bilirubin)

Administrative Requirements:

  • Cigna member ID and policy information
  • Prescriber NPI and contact information
  • ICD-10 diagnosis codes (M12.2 for TGCT, D48.1 for uncertain behavior)
  • NDC number for prescribed Turalio strength

REMS Program Status:

  • Prescriber REMS certification confirmation
  • Patient REMS enrollment initiation
Tip: Start REMS enrollment immediately while gathering other documentation. The process takes 1-3 business days and is required before any approval can be finalized.

Submission to Initial Review (1-5 Days)

How to Submit Your PA Request

Electronic Submission (Fastest) Submit through Cigna's provider portal or EviCore by Evernorth system for quickest processing.

Required Submission Elements:

  1. Completed PA form with all clinical justification
  2. All supporting documentation attached
  3. Clear indication if expedited review is needed
  4. REMS enrollment status confirmation

What Reviewers Check First

Cigna's initial review focuses on:

  • Valid TGCT diagnosis with appropriate ICD-10 coding
  • Evidence that tumor causes severe morbidity or functional limitations
  • Documentation that surgery would result in worsening function or isn't feasible
  • Confirmation of REMS program enrollment
  • Absence of contraindications (active liver disease, inability to monitor)

Washington State Requirements Under Washington law, Cigna must acknowledge PA requests and provide estimated decision timelines. Standard reviews typically take 3-14 days, while expedited requests require decisions within 24 hours.

Additional Information Requests (1-7 Days)

If Cigna requests additional information, respond quickly to avoid delays:

Common Information Requests:

  • More detailed surgical consultation explaining non-surgical candidacy
  • Additional imaging or functional assessment documentation
  • Clarification on previous treatment attempts
  • Updated liver function tests if baseline values are concerning

How to Respond Efficiently:

  • Submit additional documents through the same portal used for initial PA
  • Include the original PA reference number
  • Provide a cover letter summarizing what's being submitted
  • Follow up within 2-3 business days to confirm receipt
Note: Information requests don't restart the review clock in Washington, but prompt responses prevent unnecessary delays.

Decision Window and Outcomes

Typical Decision Timeline

Review Type Timeline Requirements
Standard PA 3-14 days Complete documentation submitted
Expedited PA Within 24 hours Clinical urgency documented
REMS Enrollment 1-3 days Concurrent with PA process

Reading Your Approval Letter

If Approved:

  • Coverage duration (typically 12 months)
  • Approved quantity and refill limitations
  • Required specialty pharmacy (REMS-certified only)
  • Monitoring requirements and reauthorization timeline

If Denied:

  • Specific denial reasons
  • Missing documentation requirements
  • Appeal rights and deadlines (180 days in Washington)
  • External review options

If Denied: Washington Appeals Process

Washington provides strong patient protections for insurance denials, including specialized external review processes.

Internal Appeals with Cigna

Timeline: File within 180 days of denial Process:

  1. Submit written appeal with additional supporting documentation
  2. Include any new clinical evidence or expert opinions
  3. Request peer-to-peer review if appropriate
  4. Cigna must respond within 30 days (standard) or 72 hours (expedited)

External Review in Washington

If internal appeals fail, Washington law provides access to Independent Review Organizations (IROs):

Filing Deadline: Within 60 days of final internal denial Process:

  1. Request external review through Cigna or directly with Washington's Office of Insurance Commissioner
  2. IRO assignment is automatic through state registry
  3. Submit any additional medical evidence within 5 business days
  4. IRO decision within 15-20 days (72 hours for expedited)

IRO Decision Authority: The IRO's decision is binding on Cigna if they overturn the denial. Contact the Washington Office of Insurance Commissioner at 1-800-562-6900 for assistance.

Renewal Cycles and Reauthorization

When Reauthorization is Needed

Cigna typically approves Turalio for 12-month periods, requiring reauthorization for continued coverage.

Reauthorization Requirements:

  • Updated clinical assessment showing continued need
  • Current liver function tests demonstrating safety
  • Documentation of treatment response or disease stability
  • Confirmation of ongoing REMS compliance

Streamlining Renewals

Start the reauthorization process 30-60 days before current approval expires:

  • Schedule required monitoring appointments
  • Update clinical documentation
  • Confirm continued REMS enrollment
  • Submit renewal PA with comparative clinical data

Timeline Visual: Key Milestones

Turalio PA Timeline in Washington

Milestone Timeline Action Required
Pre-Submission Days 0-2 Gather documentation, initiate REMS
PA Submission Day 1 Submit complete request via portal
REMS Completion Days 1-3 Complete patient/prescriber enrollment
Initial Review Days 3-7 Cigna reviews documentation
Decision/Info Request Days 5-14 Approval or request for additional info
Appeal (if needed) Days 15-45 Internal appeal process
External Review Days 46-65 IRO review if internal appeal fails

Time-Saving Tips for Faster Approval

Portal Usage Best Practices

  • Use electronic submission through Cigna's provider portal
  • Upload all documents in a single submission when possible
  • Use clear, descriptive file names for attachments
  • Follow up within 48 hours to confirm receipt

Bundled Evidence Strategy

Submit a comprehensive evidence package including:

  • Complete clinical narrative explaining medical necessity
  • All required diagnostic and imaging reports
  • Surgical consultation with clear rationale for non-surgical approach
  • Baseline safety labs and monitoring plan

Direct Specialty Routing

  • Ensure PA is routed to Cigna's oncology/specialty review team
  • Include specialty-specific language and coding
  • Reference relevant clinical guidelines and FDA labeling
From our advocates: "We've found that PAs with complete surgical assessments explaining why resection would cause 'severe morbidity or functional limitations' - using those exact FDA label terms - get approved faster than generic 'not surgical candidate' notes. The specificity matters for TGCT cases."

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient TGCT diagnosis Submit pathology report and imaging Histology confirmation, MRI showing tumor
Surgery not adequately ruled out Obtain detailed surgical consultation Notes explaining why surgery would cause severe morbidity
REMS enrollment incomplete Complete both prescriber and patient enrollment REMS confirmation certificates
Missing functional assessment Document specific limitations Range of motion tests, pain scores, functional impact
Liver safety concerns Provide baseline labs and monitoring plan ALT, AST, bilirubin levels; hepatology consultation if needed

Medical Necessity Letter Checklist

When appealing or resubmitting, ensure your prescriber includes:

  • Specific TGCT subtype and anatomical location
  • Failed or inappropriate surgical options with detailed rationale
  • Functional limitations quantified with objective measures
  • Treatment goals and expected outcomes
  • Monitoring plan for hepatotoxicity
  • References to FDA labeling and clinical guidelines

FAQ

How long does Cigna PA take for Turalio in Washington? Standard PA decisions take 3-14 days; expedited reviews within 24 hours. REMS enrollment adds 1-3 days but can be completed concurrently.

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

Can I request an expedited appeal in Washington? Yes, if delay would jeopardize your health. Expedited internal appeals receive decisions within 72 hours; expedited external reviews within 72 hours.

Does step therapy apply to Turalio? Typically no, as Turalio is indicated when surgery isn't appropriate. However, some plans may require documentation of considered alternatives like imatinib.

What specialty pharmacies can dispense Turalio? Only REMS-certified specialty pharmacies. Cigna typically uses Accredo, but verify REMS certification for your preferred pharmacy.

How much does Turalio cost without insurance? Approximately $23,850 for a 28-day supply. Manufacturer assistance programs may help with costs.

What happens if my appeal is denied? You can request external review through Washington's IRO process within 60 days. The IRO decision is binding on Cigna if they overturn the denial.

Can I continue current treatment during appeals? You may be eligible for a 31-day emergency supply if you're past your first 90 days of plan membership and facing a new restriction.

Sources & Further Reading

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying specific denial reasons and crafting point-by-point rebuttals aligned to each plan's requirements, significantly improving approval rates for specialty medications like Turalio.

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 clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For assistance with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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