By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Cigna in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Tysabri Covered by Cigna in New York

Tysabri (natalizumab) requires prior authorization from Cigna and is covered under the medical benefit as a specialty infusion. Key requirements: TOUCH program enrollment for patient, prescriber, and infusion site; documented failure of at least one MS therapy; current MRI and JCV antibody testing. Fastest path: Submit complete PA documentation through your neurologist's office, including all prior therapy records and current lab results. If denied: New York residents can appeal through Cigna (180 days) then request binding external review through the NY Department of Financial Services (4 months from final denial). Start today: Verify your TOUCH enrollment status and gather prior therapy documentation.

Table of Contents

What This Guide Covers

This comprehensive guide helps patients with multiple sclerosis and their healthcare providers navigate Cigna's prior authorization process for Tysabri (natalizumab) in New York. We'll walk through every step—from gathering required documentation to filing appeals if your initial request is denied.

Tysabri is a specialty medication that requires careful coordination between your neurologist, infusion center, and insurance company. The process can feel overwhelming, but with the right preparation and documentation, most medically necessary requests are ultimately approved.

Before You Start: Coverage Basics

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Tysabri coverage Cigna Coverage Policy IP0690
Benefit Type Medical benefit (not pharmacy) Your Cigna plan documents
TOUCH Enrollment Mandatory FDA safety program TOUCH Program
Specialist Required Neurologist or MS specialist Cigna policy requirements
Site of Care TOUCH-enrolled infusion center TOUCH facility directory

Verify Your Plan Details

First, confirm you have Cigna coverage and understand your specific plan type. Call the member services number on your insurance card to verify:

  • Your current coverage status
  • Whether Tysabri requires prior authorization (it does for all Cigna plans)
  • Your specialist copay or coinsurance for infusions
  • Whether your neurologist is in-network
Tip: If you have Medicare Advantage through Cigna, the process is similar but may have different forms. Ask specifically about Medicare Part B coverage for infused medications.

Gather What You Need

Clinical Documentation Checklist

Your neurologist's office will need to compile comprehensive documentation for the prior authorization request:

Diagnosis and Disease History:

  • ICD-10 diagnosis code for relapsing multiple sclerosis
  • Date of initial MS diagnosis
  • Current disease status and activity level
  • Recent MRI reports showing disease activity or progression

Prior Therapy Documentation:

  • Complete list of previous MS medications tried
  • Dates of treatment for each medication
  • Specific reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Documentation of treatment failures or inadequate response

Laboratory Results:

  • JCV antibody test results (required for all patients)
  • Complete blood count and liver function tests
  • Any other relevant lab work

TOUCH Program Requirements:

  • Patient TOUCH enrollment confirmation
  • Prescriber TOUCH enrollment and training completion
  • Infusion site TOUCH enrollment verification
Note: The TOUCH program is an FDA-mandated safety program. All parties must be enrolled before Tysabri can be prescribed or covered by any insurance, including Cigna.

From Our Advocates

"We've seen many Tysabri requests initially denied simply because the TOUCH enrollment wasn't complete for all parties. One patient's approval was delayed by six weeks because the infusion center hadn't finished their TOUCH training. Always verify that your patient, prescriber, and infusion site are fully enrolled before submitting the PA request—it's the most common preventable cause of delays."

Submit the Prior Authorization Request

Step-by-Step Submission Process

1. Complete Cigna's Prior Authorization Form Your neurologist's office should use Cigna's medical prior authorization form or submit through their provider portal.

2. Compile Supporting Documentation Attach all clinical documentation listed above, ensuring everything is current and complete.

3. Submit Through Proper Channels Most Cigna prior authorizations are submitted through:

  • Cigna provider portal (fastest option)
  • Fax to Cigna's specialty pharmacy team
  • Mail to the address specified on the PA form

4. Request Expedited Review if Appropriate If your MS is rapidly worsening or you're experiencing significant disability progression, request expedited review. Include a physician attestation explaining the medical urgency.

Follow-Up and Timelines

Expected Response Times

  • Standard Prior Authorization: 5-15 business days
  • Expedited Review: 72 hours for urgent cases
  • Additional Information Requests: 14 days to respond

How to Follow Up

Call Cigna member services weekly to check on your request status. Have your prior authorization reference number ready and ask specifically:

  • Current status of the review
  • Whether any additional information is needed
  • Expected decision date
  • Next steps if more documentation is required

Sample Follow-Up Script: "Hi, I'm calling to check on the status of a prior authorization request for Tysabri. My member ID is [number] and the PA reference number is [number]. Can you tell me the current status and whether any additional information is needed?"

If You Need More Information

Cigna may request additional clinical information during their review. Common requests include:

  • More detailed prior therapy documentation
  • Recent MRI reports with radiologist interpretation
  • Updated JCV antibody testing
  • Letter of medical necessity from your neurologist

Medical Necessity Letter Components

If Cigna requests a medical necessity letter, ensure it includes:

  1. Patient's specific MS diagnosis and disease course
  2. Complete prior therapy history with outcomes
  3. Current disease status and disability level
  4. Clinical rationale for Tysabri specifically
  5. References to MS treatment guidelines
  6. Expected treatment goals and monitoring plan

The letter should reference established MS treatment guidelines and explain why Tysabri is the most appropriate therapy for your specific situation.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Incomplete TOUCH enrollment Verify and complete enrollment for all parties
Insufficient prior therapy documentation Provide detailed records of failed treatments
Missing JCV antibody results Submit current JCV testing results
Lack of MRI documentation Provide recent MRI showing disease activity
Non-specialist prescriber Ensure neurologist or MS specialist is prescribing

Cigna Internal Appeals Process

You have 180 days from the denial date to file an internal appeal with Cigna. The process includes:

Level 1 Appeal (First-Level Review):

  • Submit additional clinical documentation
  • Include a detailed medical necessity letter
  • Request peer-to-peer review if appropriate
  • Decision within 30 days (72 hours if expedited)

Level 2 Appeal (Medical Director Review):

  • Available within 60 days of Level 1 denial
  • Includes peer-to-peer discussion between your neurologist and Cigna medical director
  • Final internal review before external options

Appeals Process in New York

New York External Review Rights

If Cigna's internal appeals process doesn't result in approval, New York residents have strong external review rights through the New York State Department of Financial Services (DFS).

Key Timelines:

  • 4 months from final Cigna denial to request external review
  • 72 hours for expedited external appeals
  • 30 days for standard external appeal decisions
  • $25 maximum fee (waived for Medicaid or financial hardship)

How to File External Appeal:

  1. Complete the DFS external appeal application
  2. Attach Cigna's final denial letter and all supporting documentation
  3. Submit by mail, fax, or online through the DFS portal
  4. Pay the application fee or request a waiver
Important: DFS external review decisions are legally binding on Cigna. If the external reviewer determines Tysabri is medically necessary, Cigna must provide coverage.

Additional New York Resources

Community Health Advocates: Free insurance counseling at 888-614-5400

DFS Consumer Helpline: 1-800-342-3736 for external appeal assistance

Renewal and Re-Authorization

Tysabri typically requires re-authorization every 6-12 months. Plan ahead by:

  • Calendaring your renewal date 60 days in advance
  • Gathering updated clinical documentation
  • Scheduling any required lab work or MRI scans
  • Ensuring continued TOUCH program compliance

Your neurologist should document your response to treatment, any side effects, and the continued medical necessity for ongoing therapy.

Costs and Financial Assistance

Insurance Coverage

Under most Cigna plans, Tysabri is covered as a medical benefit with specialty drug coinsurance. Your out-of-pocket costs depend on:

  • Your specific plan's specialty drug coinsurance rate
  • Whether you've met your annual deductible
  • Your plan's out-of-pocket maximum

Financial Assistance Options

  • Biogen Above MS: Patient assistance program for eligible patients
  • TOUCH Copay Program: May help with insurance copays (restrictions apply)
  • State and foundation programs: Various MS organizations offer financial assistance
Note: Copay assistance programs typically cannot be used with Medicare or Medicaid plans.

Quick Reference Checklist

Before Starting:

  • Verify Cigna coverage and in-network neurologist
  • Confirm TOUCH enrollment for patient, prescriber, and infusion site
  • Gather all prior therapy documentation

For Prior Authorization:

  • Complete clinical documentation package
  • Submit through appropriate channel (portal preferred)
  • Request expedited review if medically urgent
  • Follow up weekly on status

If Denied:

  • Review denial reason carefully
  • File Level 1 appeal within 180 days
  • Include comprehensive medical necessity letter
  • Consider peer-to-peer review request

For External Appeal (if needed):

  • File DFS external appeal within 4 months
  • Include all Cigna correspondence and clinical documentation
  • Pay fee or request waiver

Frequently Asked Questions

How long does Cigna prior authorization take for Tysabri in New York? Standard review takes 5-15 business days. Expedited review for urgent cases is completed within 72 hours.

What if Tysabri isn't on my Cigna formulary? Tysabri is typically covered as a medical benefit rather than appearing on pharmacy formularies. Your neurologist can request a formulary exception if needed.

Can I get expedited review for my Tysabri request? Yes, if delay would seriously jeopardize your health or ability to function. Your neurologist must provide written attestation of medical urgency.

What happens if I'm JCV antibody positive? Cigna may require additional documentation of the risk-benefit analysis and enhanced monitoring plans, but JCV positivity doesn't automatically disqualify coverage.

How do I find a TOUCH-enrolled infusion center? Use the facility directory on the TOUCH program website to locate enrolled infusion centers in your area.

What if my neurologist isn't familiar with Cigna's requirements? Share this guide with your healthcare team. Counterforce Health also provides tools and resources to help clinicians navigate complex prior authorization requirements and craft effective appeals when insurance denials occur.

Can I appeal if my renewal is denied? Yes, the same appeal rights apply to renewal denials. Gather updated clinical documentation showing continued medical necessity.

What if I move to another state while on Tysabri? Contact Cigna immediately to understand how your coverage may change. You may need to find new in-network providers and TOUCH-enrolled facilities.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create targeted rebuttals that align with each payer's specific requirements, pulling the right clinical evidence and regulatory citations to support medical necessity arguments. Learn more at www.counterforcehealth.org.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider about treatment options and work with them to navigate insurance requirements. For personalized assistance with coverage issues, contact your insurance company directly or seek help from qualified patient advocates.

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