By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (ravulizumab) Covered by Cigna in Georgia: Appeals, Forms & Timelines

Answer Box: Getting Ultomiris Covered by Cigna in Georgia

If Cigna denied your Ultomiris (ravulizumab) prescription in Georgia, you have clear appeal rights with specific deadlines. Start with an internal appeal within 180 days of your denial letter. Include a medical necessity letter from your doctor addressing the exact denial reason. If denied again, request external review with the Georgia Insurance Commissioner within 120 days of the final internal decision. Most Ultomiris denials involve missing clinical documentation or step therapy requirements—both are fixable with proper evidence.

Your first step today: Call your doctor's office to request a peer-to-peer review with Cigna and gather all prior treatment records.

Table of Contents

  1. Read Your Denial Letter
  2. Coverage Requirements at a Glance
  3. Fixable Denial Causes
  4. First-Level Internal Appeal
  5. Peer-to-Peer Review Process
  6. External Review in Georgia
  7. Medical Necessity Letter Template
  8. Common Denial Reasons & Solutions
  9. Cost-Saving Options
  10. When to Escalate
  11. FAQ

Read Your Denial Letter

Your Cigna denial letter contains critical information that determines your next steps. Look for these key elements:

Essential Details to Extract:

  • Denial date (starts your appeal clock)
  • Reference number (include in all correspondence)
  • Specific reason code (medical necessity, step therapy, non-formulary)
  • Appeals deadline (typically 180 days for internal appeals)
  • Required documentation for appeals
Tip: If your denial mentions "not medically necessary" or "experimental," you have strong grounds for appeal with proper clinical evidence.

Ultomiris denials often cite missing REMS certification, inadequate vaccination records, or failure to try step therapy alternatives. Each reason requires a different appeal strategy.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all indications Cigna PA List
FDA Indications Only PNH, aHUS, gMG (AChR+), NMOSD (AQP4+) Cigna Policy
REMS Certification Prescriber must be certified FDA REMS
Meningococcal Vaccination Required 2+ weeks before treatment Cigna Policy
Internal Appeal Deadline 180 days from denial Cigna Appeals
External Review Deadline 120 days from final denial Georgia External Review

Fixable Denial Causes

Many Ultomiris denials can be overturned by addressing documentation gaps:

Missing Clinical Evidence:

  • Diagnosis confirmation with specific antibody tests (anti-AChR for gMG, anti-AQP4 for NMOSD)
  • Lab results showing disease activity (LDH levels for PNH, platelet counts for aHUS)
  • Documentation of prior treatment failures or contraindications

Incomplete Safety Requirements:

  • REMS certification status
  • Meningococcal vaccination records (must cover serogroups A, C, W, Y, and B)
  • Monitoring plan for infection risk

Administrative Issues:

  • Incorrect diagnosis codes
  • Missing prior authorization forms
  • Outdated clinical notes

Counterforce Health specializes in turning these documentation gaps into successful appeals by identifying exactly what evidence payers need and crafting targeted rebuttals that address each denial reason systematically.

First-Level Internal Appeal

Your internal appeal is your strongest opportunity to overturn the denial. Cigna must respond within specific timeframes and consider all new evidence you provide.

Step-by-Step Internal Appeal Process

  1. Submit Within 180 Days of your denial letter date
  2. Use Cigna's Appeal Form or write a formal letter including:
    • Your name, member ID, and group number
    • Denial letter date and reference number
    • Specific request: "I appeal the denial of Ultomiris (ravulizumab)"
    • Medical necessity justification (see template below)
  3. Include Required Documents:
    • Copy of denial letter
    • Medical necessity letter from prescriber
    • Clinical notes and lab results
    • Prior treatment records showing failures/intolerances
  4. Submit Via:
    • Cigna member portal
    • Fax: 1-866-873-8279
    • Mail to address on your denial letter

Timeline: Cigna has up to 30 days for standard appeals, 72 hours for expedited appeals involving urgent medical situations.

Peer-to-Peer Review Process

A peer-to-peer review allows your doctor to speak directly with a Cigna medical director. This can be highly effective for complex cases like Ultomiris, where clinical nuances matter.

How to Request Peer-to-Peer Review

Your doctor's office should:

  1. Call Cigna at 1-800-882-4462
  2. Request peer-to-peer review for Ultomiris denial
  3. Provide member information and denial reference number
  4. Schedule call within 5 business days

Physician Preparation Checklist

  • Patient's complete clinical history including diagnosis date and severity
  • Prior treatment timeline with specific medications, doses, and outcomes
  • Lab results demonstrating disease activity or treatment response
  • Guidelines supporting Ultomiris use for the specific indication
  • Safety documentation including vaccination records and monitoring plan
Note: Peer-to-peer reviews have higher success rates when physicians can demonstrate why alternatives are inadequate or contraindicated for the specific patient.

External Review in Georgia

If Cigna denies your internal appeal, Georgia law provides an independent external review process through the state Insurance Commissioner.

Georgia External Review Process

Eligibility: Denials based on medical necessity, experimental/investigational status, or appropriateness of care

How to Request:

  1. File within 120 days of Cigna's final internal denial
  2. Contact Georgia Insurance Commissioner:
  3. Submit required forms (provided with your final denial letter)

Timeline:

  • Commissioner notifies Cigna within 1 business day
  • Independent review organization assigned
  • Decision within 45 days (72 hours for urgent cases)
  • Decision is binding on Cigna

Cost: Free to consumers

The external review process in Georgia has helped many patients access expensive specialty medications when insurers initially denied coverage based on overly restrictive interpretations of medical necessity.

Medical Necessity Letter Template

Your prescriber's medical necessity letter is crucial for appeal success. Here's a template structure:

[Date]
[Cigna Medical Director]
[Address from denial letter]

Re: Appeal for Ultomiris (ravulizumab) Coverage
Patient: [Name], DOB: [Date]
Member ID: [Number]
Denial Reference: [Number]

Dear Medical Director,

I am appealing the denial of Ultomiris for my patient diagnosed with [specific condition: PNH/aHUS/gMG/NMOSD]. The denial reason stated [insert exact reason]. Based on clinical evidence and this patient's history, Ultomiris is medically necessary because:

**Patient Clinical Status:**
- Diagnosis: [Include ICD-10 code and date]
- Disease severity: [Specific lab values, functional status]
- Prior treatments: [List medications tried, dates, outcomes]

**Medical Necessity Justification:**
- FDA approval for this indication: [Reference prescribing information]
- Clinical guidelines support: [Cite relevant medical society guidelines]
- Patient-specific factors: [Why alternatives inadequate/contraindicated]

**Safety Compliance:**
- REMS certification: [Confirm prescriber certification]
- Vaccination status: [Document meningococcal vaccines completed]
- Monitoring plan: [Outline infection surveillance protocol]

Due to [disease progression/symptom severity], expedited approval is warranted to prevent further complications.

Sincerely,
[Physician Name, Credentials]
[Practice Information]

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Provide disease-specific lab values, functional assessments, and guideline citations
"Step therapy not completed" Document prior treatment failures, intolerances, or contraindications with specific dates and outcomes
"REMS requirements not met" Confirm prescriber certification and submit vaccination records
"Experimental/investigational" Reference FDA approval for specific indication and peer-reviewed efficacy studies
"Quantity/dosing exceeds guidelines" Justify weight-based dosing with patient parameters and prescribing information

Cost-Saving Options

While appealing your denial, explore these cost assistance programs:

Manufacturer Support:

  • Alexion Access Navigator provides coverage support and patient assistance
  • Copay assistance may reduce out-of-pocket costs for eligible patients

Foundation Programs:

  • Patient advocate foundations often provide grants for rare disease medications
  • Income-based eligibility varies by program

State Resources:

  • Georgia residents may qualify for additional support through state pharmaceutical assistance programs

When to Escalate

Contact the Georgia Insurance Commissioner if:

  • Cigna doesn't respond within required timeframes
  • You believe the denial violates state insurance law
  • The appeals process seems unfair or biased

Georgia Department of Insurance Consumer Services:

Counterforce Health helps patients navigate complex appeals by analyzing denial letters, identifying the strongest evidence for each case, and ensuring all procedural requirements are met to maximize the chance of approval.

FAQ

How long does Cigna prior authorization take for Ultomiris in Georgia? Standard PA decisions: up to 5 business days. Expedited reviews (urgent cases): within 24 hours.

What if Ultomiris isn't on Cigna's formulary? You can request a formulary exception with medical necessity justification. Non-formulary doesn't mean automatic denial if medically necessary.

Can I request expedited appeal in Georgia? Yes, if delaying treatment could seriously jeopardize your health. Document the urgency in your appeal request.

Does step therapy apply if I failed treatments in another state? Yes, but you must provide documentation of prior treatment attempts and outcomes from your previous providers.

What happens if external review denies my appeal? External review decisions are final for the administrative process. Legal action may be an option depending on circumstances.

How much does Ultomiris cost without insurance? Annual costs typically range from $474,000-$569,000, varying by weight and dosing frequency.

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 company for guidance specific to your situation. Appeal deadlines and requirements may change; verify current information with official sources.

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