By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (natalizumab) Covered by Cigna in Michigan: PA Forms, Appeals Timeline & Approval Checklist

Answer Box: Getting Tysabri Covered by Cigna in Michigan

Cigna requires prior authorization for Tysabri (natalizumab) in Michigan with step therapy requirements or documented highly active MS. The fastest path: (1) Have your neurologist submit PA via Evicore by Evernorth or CoverMyMeds with JCV antibody results, recent MRI reports, and detailed prior DMT failure documentation. (2) If denied, file internal appeal within 180 days. (3) Request Michigan DIFS external review within 127 days of final denial. Most approvals require either failed trial of one formulary DMT (interferons, Tecfidera, Copaxone) OR aggressive disease criteria with neurologist documentation.

Table of Contents

  1. Plan Types & Network Requirements
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Step Therapy & Medical Necessity Criteria
  5. Specialty Pharmacy Requirements
  6. Submission Process & Forms
  7. Appeals Process in Michigan
  8. Cost Considerations
  9. Common Denial Reasons & Solutions
  10. FAQ

Plan Types & Network Requirements

Cigna HMO vs PPO vs EPO Differences

Your Cigna plan type affects how you access neurologist care, but all plan types follow the same prior authorization rules for Tysabri:

Plan Type Neurologist Access Network Requirements PA Rules
HMO May need PCP referral (varies by plan) In-network only Same PA requirements
PPO Direct access, no referral needed In or out-of-network (higher cost out-of-network) Same PA requirements
EPO Usually no referral required In-network only Same PA requirements

Action Step: Check your Cigna ID card for plan type and call the member services number to confirm if neurologist referrals are required.

Neurologist Requirements

Cigna's natalizumab policy specifically requires that Tysabri be "prescribed by or in consultation with a neurologist or physician who specializes in MS." This applies regardless of your plan type.

Formulary Status & Tier Placement

Specialty Tier Placement

Tysabri is classified as a specialty medication on Cigna formularies, typically placed on Tier 4 (Specialty Drugs) for most commercial plans. According to Cigna's 2025 formulary documents, specialty drugs require:

  • Prior authorization (PA)
  • Use of preferred specialty pharmacy
  • Higher cost-sharing than lower tiers

Formulary Verification

Check your exact tier and coverage by:

  1. Logging into myCigna.com
  2. Using the "Price a Medication" tool
  3. Looking for "PA" markers indicating prior authorization required

Prior Authorization Requirements

Core Documentation Requirements

Based on Cigna's Tysabri PA form, you'll need:

Clinical Documentation:

  • Confirmed diagnosis of relapsing form of MS (RRMS, active SPMS, or CIS)
  • ICD-10 diagnostic codes
  • Recent MRI reports (within 3 months)
  • JCV antibody test results and date
  • Complete prior DMT history with outcomes

Safety Requirements:

  • TOUCH program enrollment confirmation
  • Baseline laboratory results
  • Infusion site verification

Prescriber Information:

  • Neurologist or MS specialist credentials
  • Medical necessity letter

JCV Antibody Testing Requirements

Cigna requires baseline JCV antibody testing for all Tysabri patients as part of PML risk assessment. The test must include:

  • Positive or negative status
  • Date of testing
  • Laboratory report attached to PA

Ongoing monitoring: JCV-negative patients need annual retesting; JCV-positive patients require testing every 6 months.

MRI Documentation Standards

Baseline Requirements:

  • Brain MRI with FLAIR and DWI sequences
  • Report dated within 3 months of Tysabri start
  • Documentation of disease activity or high lesion burden

Follow-up Schedule:

  • JCV-negative: Annual MRI
  • JCV-positive: Every 6 months
  • High-risk patients: Every 3 months

Step Therapy & Medical Necessity Criteria

Two Pathways to Approval

Cigna's medical policy offers two routes:

Option 1: Step Therapy Completion Document inadequate efficacy or significant intolerance to at least one MS disease-modifying therapy, such as:

  • Interferon betas (Avonex, Betaseron, Rebif)
  • Glatiramer acetate (Copaxone, Glatopa)
  • Dimethyl fumarate (Tecfidera)
  • Teriflunomide (Aubagio)
  • Fingolimod (Gilenya)
  • Ocrelizumab (Ocrevus)

Option 2: Highly Active/Aggressive MS Document any of the following without prior DMT requirement:

  • Rapidly advancing physical deterioration
  • Disabling relapses with poor steroid response
  • MRI showing highly active disease (new/enlarging T2 lesions, gadolinium enhancement)
  • MS-related cognitive impairment
Tip: The "highly active MS" pathway often provides faster approval but requires detailed neurologist documentation of disease severity.

Specialty Pharmacy Requirements

Accredo Specialty Pharmacy

Most Cigna plans require Tysabri to be dispensed through Accredo, Cigna's preferred specialty pharmacy partner. Key points:

  • Tysabri is typically covered as a medical benefit (not pharmacy benefit) when infused
  • Accredo coordinates with infusion centers
  • Patient enrollment required before first infusion

Infusion Site Requirements

  • Must participate in TOUCH program
  • In-network with Cigna (verify before scheduling)
  • Proper IV infusion capabilities and monitoring

Submission Process & Forms

Electronic Prior Authorization Options

Submit PA through these verified portals:

  1. CoverMyMeds - Free account for Express Scripts PAs
  2. Evicore by Evernorth - Select "Pharmacy Drug (Express Scripts Coverage)"
  3. MyAccredoPatients.com - Electronic referral system
  4. Surescripts CompletEPA - Integrated with EHR systems

Backup Submission Methods

If electronic submission isn't available:

  • Express Scripts: 800-835-3784
  • Cigna: 800-882-4462
  • Include all clinical documentation to avoid delays

Timeline Expectations

  • Standard PA review: 2-3 business days
  • Expedited review: 24 hours (urgent cases)
  • Member tracking: Via myCigna app under Prescriptions > Prior Authorizations

Appeals Process in Michigan

Internal Appeal with Cigna

Filing Deadline: 180 days from denial date Decision Timeline: 30 days for pre-service denials

How to File:

  1. Call Cigna customer service (number on ID card)
  2. Request "Customer Appeal Request" form
  3. Submit with supporting documentation

Required Documentation:

  • Original denial letter
  • Enhanced medical necessity letter
  • Additional clinical evidence
  • Peer-reviewed literature supporting Tysabri use

Michigan DIFS External Review

After Cigna's final internal denial, you can request external review through Michigan's Department of Insurance and Financial Services.

Key Details:

  • Filing deadline: 127 days from Cigna's final adverse determination
  • Standard review: Completed within regulatory timeframes
  • Expedited review: 72 hours (with physician urgency letter)

How to File:

  • Online at Michigan DIFS website
  • Phone: 877-999-6442 (toll-free)
  • Submit required forms and all denial documentation
Note: DIFS external review decisions are binding on Cigna. If approved, Cigna must provide coverage as directed.

Cost Considerations

Typical Cost-Sharing Structure

As a specialty tier medication, expect:

  • Deductible: May apply before coverage begins
  • Coinsurance: Typically 20-40% of drug cost
  • Copay: Alternative to coinsurance on some plans

Potential Cost-Saving Options

  • Biogen support programs (verify eligibility at manufacturer website)
  • Foundation grants for qualifying patients
  • State pharmaceutical assistance (if available in Michigan)

Note: This information is educational only. Consult your plan documents for exact cost-sharing details.

Common Denial Reasons & Solutions

Denial Reason Solution
Missing TOUCH enrollment Provide enrollment confirmation from prescriber and infusion site
Inadequate prior therapy documentation Submit detailed DMT history with dates, doses, and failure reasons
Non-relapsing MS diagnosis Clarify diagnosis as RRMS, active SPMS, or CIS with supporting documentation
Missing JCV antibody results Order and submit current JCV antibody test with date
Insufficient MRI documentation Provide recent brain MRI with FLAIR sequences and radiologist interpretation
Not prescribed by neurologist Ensure neurologist or MS specialist is listed as prescriber

From Our Advocates

In our experience helping patients navigate Tysabri approvals, the most successful submissions include a comprehensive "MS treatment timeline" document that clearly shows each prior therapy tried, the specific reason it failed (with dates), and how those failures led to the medical necessity for Tysabri. This approach helps reviewers quickly understand the clinical rationale without having to piece together information from multiple sources.

FAQ

How long does Cigna prior authorization take for Tysabri in Michigan? Standard PA reviews take 2-3 business days via electronic submission. Expedited reviews for urgent cases are completed within 24 hours.

What if Tysabri is non-formulary on my Cigna plan? You can request a formulary exception with enhanced clinical documentation. The process is similar to standard PA but requires additional justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if your health condition may be seriously jeopardized by delay. Your neurologist must provide a supporting letter stating the medical urgency.

Does step therapy apply if I failed DMTs outside Michigan? Yes, Cigna accepts prior therapy failures from any location as long as they're properly documented with dates and clinical rationale.

What happens if DIFS external review denies my appeal? You have 60 days from the external review decision to seek judicial review in Michigan circuit court, though this is rarely necessary.

How often do I need to renew Tysabri prior authorization? Typically annually. Renewals require updated clinical documentation showing continued medical necessity and beneficial response to treatment.

Counterforce Health helps patients and clinicians navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies specific coverage criteria, and drafts point-by-point rebuttals aligned with payer policies. For more information about streamlining your prior authorization process, visit www.counterforcehealth.org.

When dealing with Tysabri denials, Counterforce Health's platform can help identify which specific Cigna criteria weren't met and generate targeted appeal letters that address each point systematically.

Sources & Further Reading

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 documents for specific coverage details. Insurance policies and requirements may change; verify current information with your plan before making treatment decisions.

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