By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by Cigna in Illinois: Complete PA Guide and Appeal Process

Quick Answer: Getting Ultomiris Covered by Cigna in Illinois

Ultomiris requires prior authorization from Cigna for all conditions (PNH, aHUS, gMG, NMOSD). Submit the official Cigna PA form with complete diagnosis documentation, specialist involvement, and vaccination records. Most requests are processed within 5-7 business days. If denied, you have 180 days to file an internal appeal, then 30 days for external review through Illinois Department of Insurance. First step today: Confirm your specialist is Cigna in-network and request they complete the PA form with all required clinical documentation.

Table of Contents

  1. Cigna Plan Types & Specialist Access
  2. Ultomiris Formulary Status & Coverage
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Requirements
  5. Cost-Share Basics
  6. Fastest Path to Approval
  7. Common Denial Reasons & Solutions
  8. Illinois Appeal Process
  9. Cost Assistance Programs
  10. FAQ

Cigna Plan Types & Specialist Access

Your Cigna plan type determines whether you need referrals to see the specialists who prescribe Ultomiris:

HMO Plans: You must get a referral from your primary care provider (PCP) to see a network neurologist or hematologist. Contact your PCP first to request the referral.

PPO Plans: No referral required. You can self-refer to any in-network specialist, though out-of-network visits cost more.

EPO Plans: Generally no referral needed for in-network specialists, but you must stay in-network (no out-of-network coverage except emergencies).

Note: All plan types require prior authorization for Ultomiris regardless of specialist type.

Ultomiris Formulary Status & Coverage

Ultomiris is placed on Cigna's highest specialty tier (Tier 4 or 5) for 2025, meaning the highest out-of-pocket costs. Both Ultomiris and Soliris require prior authorization and may be subject to step therapy requirements, meaning you may need to try one before the other.

Coverage at a Glance

Requirement What It Means Source
Prior Authorization Required for all indications Cigna PA Form
Formulary Tier Specialty Tier (highest cost) 2025 IL Formulary
Step Therapy May apply vs. Soliris Coverage Updates
Specialist Required Yes (by indication) Coverage Policy IP0550

Prior Authorization Requirements

Cigna requires comprehensive documentation for Ultomiris approval across all FDA-approved conditions:

Required Documentation

For All Indications:

  • Complete Cigna Ultomiris PA form
  • Confirmed diagnosis with appropriate lab tests
  • Specialist involvement (hematologist for PNH, nephrologist for aHUS, neurologist for gMG/NMOSD)
  • Meningococcal vaccination documentation (required by REMS program)

Condition-Specific Requirements:

  • PNH: Flow cytometry results confirming diagnosis
  • aHUS: Must exclude STEC-HUS; nephrologist consultation required
  • gMG: AChR antibody-positive status; neurologist involvement; documentation of prior therapy failures (typically pyridostigmine and two immunosuppressants)
  • NMOSD: AQP4 antibody-positive status; neurologist involvement

Submission Methods

Submit via:

  • Fax: (855) 840-1678
  • Electronic: CoverMyMeds platform
  • Provider Portal: Cigna's online system

Processing Time: 5-7 business days for standard requests; 72 hours for expedited reviews when delay risks significant harm.

Specialty Pharmacy Requirements

Cigna requires Ultomiris to be dispensed through Accredo (NCPDP 4436920), their preferred specialty pharmacy partner. Your prescription will automatically be routed to Accredo once approved.

Patient Setup Steps:

  1. Accredo will contact you after PA approval
  2. Complete enrollment and insurance verification
  3. Schedule delivery or infusion site coordination
  4. Confirm ongoing refill schedule (every 8 weeks for maintenance dosing)

Cost-Share Basics

As a specialty tier medication, Ultomiris typically requires coinsurance (percentage of drug cost) rather than a flat copay. Annual costs often exceed $450,000, making manufacturer assistance programs crucial for most patients.

Important: This information is educational only. Consult your plan documents or call Cigna member services for specific cost-share details.

Fastest Path to Approval

Step-by-Step Process

  1. Confirm Network Status - Verify your specialist is Cigna in-network via the provider directory
  2. Gather Documentation - Collect diagnosis confirmation, prior treatment records, and vaccination status
  3. Complete PA Form - Specialist completes Cigna's official form with all clinical details
  4. Submit Complete Package - Include all required attachments via fax (855) 840-1678 or CoverMyMeds
  5. Track Status - Follow up within 3-5 business days if no response
  6. Accredo Setup - Complete specialty pharmacy enrollment once approved
  7. Schedule Treatment - Coordinate infusion site and timing

Timeline: Allow 7-10 business days total from submission to first infusion.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documentation Needed
Insufficient diagnosis documentation Resubmit with complete lab results Flow cytometry (PNH), antibody tests (gMG/NMOSD)
Missing specialist involvement Add specialist consultation Referral letter from appropriate specialist
Step therapy not completed Document prior therapy or request exception Treatment history, failure/intolerance records
Vaccination requirement not met Provide vaccination proof Meningococcal vaccine records or scheduling
Dosing outside FDA parameters Justify medical necessity Clinical rationale for specific dosing needs

Illinois Appeal Process

Illinois provides strong patient rights for insurance appeals with specific deadlines:

Internal Appeal with Cigna

  • Deadline: 180 days from denial date
  • Cigna Response Time: 15 business days (24 hours if expedited)
  • Required: Written appeal with clinical documentation addressing each denial reason

External Review (Illinois Department of Insurance)

  • Deadline: 30 days after final internal denial (shorter than most states)
  • Review Time: 5 business days for standard; 72 hours for expedited
  • Decision: Binding if overturned - Cigna must provide coverage
  • Cost: Free to patients
  • Contact: Illinois DOI at (877) 527-9431
Critical: Illinois has one of the shortest external review deadlines in the U.S. Don't delay filing.

When to Request Expedited Review

Request expedited processing if delay would:

  • Seriously jeopardize your health
  • Risk permanent disability
  • Interfere with your ability to regain maximum function

Cost Assistance Programs

Given Ultomiris's high annual cost (often $450,000+), financial assistance is typically essential:

Manufacturer Programs:

  • Alexion Access Navigator: Patient support program offering copay assistance and case management
  • Eligibility: Varies by insurance type and income

Foundation Assistance:

  • Patient Advocate Foundation
  • HealthWell Foundation
  • National Organization for Rare Disorders (NORD)

State Resources:

  • Illinois Department of Insurance consumer assistance: (877) 527-9431
Tip: Apply for manufacturer assistance before starting treatment, as some programs have enrollment deadlines.

From our advocates: We've seen cases where initial Ultomiris denials were overturned simply by adding more detailed documentation of prior treatment failures and specialist consultation notes. The key is addressing every specific denial reason with clinical evidence - don't assume reviewers will infer medical necessity from incomplete records.

FAQ

How long does Cigna prior authorization take for Ultomiris in Illinois? Standard requests: 5-7 business days. Expedited requests (when delay risks health): 72 hours. Source: Cigna PA Policy

What if Ultomiris is non-formulary on my specific plan? Request a formulary exception with clinical justification for why covered alternatives aren't appropriate. Include specialist documentation of medical necessity.

Can I get an expedited appeal in Illinois? Yes, if delay would seriously jeopardize your health. Both Cigna internal appeals and Illinois external reviews offer expedited processing.

Does step therapy apply if I've tried Soliris outside Illinois? Yes, prior treatment history from any state counts toward step therapy requirements. Provide complete documentation of previous therapies and outcomes.

What happens if I miss the 30-day external review deadline? Illinois's deadline is strict. Contact the Illinois Department of Insurance immediately to discuss options, as exceptions are rare.

Can I use a different specialty pharmacy besides Accredo? Cigna typically requires Accredo for Ultomiris. Exceptions may be granted for geographic access issues or medical necessity - request approval in advance.

Sources & Further Reading

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed rebuttals. Our platform streamlines the complex prior authorization process, helping ensure patients get access to the medications they need.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult your healthcare provider for medical decisions and your insurance company or a qualified professional for coverage questions. For personalized assistance with Cigna appeals in Illinois, consider consulting Counterforce Health or contacting the Illinois Department of Insurance consumer assistance line at (877) 527-9431.

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