By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (Ravulizumab) Covered by Cigna in Ohio: Prior Authorization, Appeals, and Alternative Options

Quick Answer: Getting Ultomiris Covered by Cigna in Ohio

Cigna requires prior authorization for Ultomiris (ravulizumab) through Express Scripts/Accredo specialty pharmacy. Your hematologist or neurologist must submit medical necessity documentation showing diagnosis confirmation (ICD-10 codes), prior therapy failures, and vaccination requirements. If denied, Ohio residents have 180 days for internal appeals, then external review through the Ohio Department of Insurance. First step today: Have your prescriber check Cigna's formulary status and submit PA via EviCore by Evernorth or call Express Scripts at 1-866-494-2111 for urgent cases.

Table of Contents

When Alternatives Make Sense

Before pursuing a formulary exception for Ultomiris (ravulizumab), consider whether alternatives might provide similar clinical outcomes with easier approval. This is particularly relevant if you're newly diagnosed or haven't tried other complement inhibitors.

Clinical scenarios where alternatives are appropriate:

  • First-line treatment for PNH, aHUS, myasthenia gravis, or NMOSD
  • No contraindications to eculizumab or biosimilars
  • Preference for lower-cost options while maintaining efficacy
  • Insurance requires step therapy compliance

When to prioritize Ultomiris specifically:

  • Poor adherence with every-2-week infusions (Ultomiris is every 8 weeks)
  • Documented failure or intolerance to eculizumab
  • Lifestyle factors requiring extended dosing intervals
  • Switching from eculizumab with stable disease control

Typical Formulary Alternatives

Complement C5 Inhibitors

Eculizumab (Soliris) - The reference standard

  • Dosing: Every 2 weeks after loading phase
  • Same indications as Ultomiris (PNH, aHUS, gMG, NMOSD)
  • Often preferred by insurers as established therapy
  • Requires meningococcal vaccination like Ultomiris

Eculizumab Biosimilars (2025 launches)

  • Epysqli (eculizumab-aagh): 30% discount from Soliris, available April 2025
  • Bkemv (eculizumab-aeeb): 10% discount, FDA-approved May 2024
  • Same efficacy/safety as Soliris per phase 3 trials
  • May have easier formulary access due to cost savings

Alternative Complement Inhibitors

Pegcetacoplan (Empaveli) - For PNH only

  • C3 inhibitor, subcutaneous twice weekly
  • Different mechanism may benefit patients with breakthrough hemolysis on C5 inhibitors

Crovalimab (Piasky) - Emerging option

  • Monthly subcutaneous or IV dosing for PNH
  • Not yet widely available in US formularies
From our advocates: "We've seen several patients successfully transition from denied Ultomiris requests to approved eculizumab biosimilars, then later switch to Ultomiris once they've established clinical stability. The key is documenting response and any adherence challenges with the shorter dosing interval."

Coverage Requirements at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all indications Accredo specialty pharmacy Cigna Specialty Pharmacy Guide
Formulary Tier High-tier specialty (verify current) myCigna.com drug search Cigna Drug Lists
Step Therapy Likely eculizumab first Plan-specific formulary Contact Cigna at 800.753.2851
Quantity Limits Per FDA dosing (weight-based) Express Scripts PA system Express Scripts PA FAQ
Site of Care Accredo specialty pharmacy required Post-approval enrollment Accredo Prior Authorization
Diagnosis Codes PNH: D59.5; gMG: G70.00; aHUS: D59.3; NMOSD: G36.0 ICD-10 coding FDA prescribing information
Appeals Deadline 180 days internal; 180 days external Ohio insurance law Ohio Department of Insurance

Step-by-Step: Fastest Path to Approval

1. Verify Coverage Status

Who: Patient or clinic staff
Action: Check current formulary status via myCigna.com or call member services
Timeline: Same day
Document needed: Insurance card, member ID

2. Gather Medical Documentation

Who: Prescribing specialist (hematologist/neurologist)
Action: Compile diagnosis confirmation, lab results, prior therapy records
Timeline: 1-2 business days
Documents needed: Recent labs (within 30 days), treatment history, vaccination records

3. Submit Prior Authorization

Who: Prescriber or clinic staff
Action: Submit via EviCore by Evernorth (preferred) or CoverMyMeds Express Scripts portal
Timeline: Complete within 1 business day of submission
Alternative: Fax to Accredo at 888.302.2028 for urgent cases

4. Follow Up on Decision

Who: Patient and clinic
Action: Check status via myCigna.com or call Express Scripts
Timeline: Standard 5-15 business days; urgent 72 hours
Next step: If approved, enroll with Accredo; if denied, prepare appeal

5. Enroll with Specialty Pharmacy

Who: Patient
Action: Contact Accredo at 844.516.3319 for enrollment and scheduling
Timeline: 2-3 business days for first shipment coordination
Documents: Insurance approval, prescriber coordination for infusion site

Formulary Exception Strategy

When Ultomiris isn't covered or requires extensive step therapy, request a formulary exception through Cigna's standard process.

Strongest exception arguments:

  1. Medical contraindication to formulary alternatives (document specific reactions)
  2. Adherence challenges with every-2-week eculizumab infusions
  3. Treatment failure on step therapy requirements despite adequate trial
  4. Quality of life impact from frequent medical appointments

Required physician certification:

  • Previous formulary medication was "detrimental to health or ineffective"
  • Formulary alternative is "likely to be ineffective or harmful"
  • Clinical rationale with supporting literature

Timeline: Standard review within 2 business days; expedited review within 24 hours for urgent clinical situations.

Switching Logistics

From Eculizumab to Ultomiris

Timing: Initiate Ultomiris loading dose 2 weeks after final eculizumab infusion
Coordination: No washout period required; schedule at next eculizumab appointment slot
Monitoring: Weekly LDH and hemoglobin initially to confirm therapeutic continuity
Vaccination: Meningococcal vaccination must be current (no additional doses needed if previously vaccinated for eculizumab)

Pharmacy Coordination

Current Accredo patients: Coverage transfer typically seamless
New to specialty pharmacy: Allow 5-7 business days for enrollment and first shipment
Insurance changes: Re-verify PA approval and Accredo network status

Re-trying for Ultomiris Later

If initially denied, document these factors during alternative therapy trials:

Clinical response metrics:

  • LDH normalization (or lack thereof)
  • Transfusion requirements and frequency
  • Breakthrough hemolysis episodes
  • Kidney function stability (aHUS)
  • Functional assessment scores (MG-ADL for myasthenia gravis)

Quality of life factors:

  • Missed work/school due to infusion schedule
  • Travel limitations with every-2-week dosing
  • Caregiver burden for transportation
  • Patient-reported outcome measures

Document adherence challenges:

  • Missed doses due to scheduling conflicts
  • Insurance authorization delays affecting continuity
  • Geographic barriers to infusion centers

Counterforce Health specializes in turning these documented challenges into targeted appeals that align with payer-specific criteria, helping patients and clinicians build stronger cases for Ultomiris approval.

Appeals Process in Ohio

Internal Appeals (First Level)

Deadline: 180 days from denial notice
Submission: Written request to Cigna member services or online portal
Timeline: Standard determination within 30 days; expedited within 72 hours
Required: Copy of denial letter, clinical rationale, supporting documentation

External Review

Eligibility: After completing internal appeals or if Cigna fails to respond timely
Deadline: 180 days from final internal denial
Process: Submit request to Cigna, who forwards to Ohio Department of Insurance
Timeline: Standard 30 days; expedited 72 hours for urgent cases
Binding: IRO decision is final and binding on Cigna

Ohio-Specific Advantages

  • ODI can independently determine external review eligibility even if Cigna objects
  • Consumer hotline: 1-800-686-1526 for appeals assistance
  • UHCAN Ohio provides consumer advocacy support

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Submit specialist letter with guideline references, lab values, functional assessments
"Step therapy required" Request exception with documented contraindications or prior failures outside current plan
"Experimental/investigational" Provide FDA approval documentation and peer-reviewed efficacy studies
"Quantity exceeds limits" Submit weight-based dosing calculations per FDA label with prescriber attestation
"Site of care restriction" Coordinate with Accredo for approved infusion network; document access barriers

FAQ

How long does Cigna prior authorization take for Ultomiris in Ohio?
Standard review: 5-15 business days. Expedited review (with clinical urgency documentation): 72 hours. Submit via EviCore by Evernorth for fastest processing.

What if Ultomiris is non-formulary on my Cigna plan?
Request a formulary exception through your prescriber. Provide clinical rationale for why formulary alternatives are inappropriate. Cigna's exception process requires physician certification within 2 business days.

Can I request an expedited appeal in Ohio?
Yes, for situations where delays could "seriously jeopardize life, health, or ability to regain maximum function." Both Cigna internal appeals and Ohio external reviews offer expedited timelines (72 hours vs. standard 30 days).

Does step therapy apply if I failed eculizumab in another state?
Document prior therapy failure with clinical records, including drug name, dosing, duration, and reason for discontinuation. Cigna should accept out-of-state treatment history for step therapy completion.

What's the difference between Ultomiris and eculizumab biosimilars?
Ultomiris offers every-8-week dosing vs. every-2-week for eculizumab/biosimilars. Clinical efficacy is similar, but Ultomiris may improve adherence and quality of life. Biosimilars like Epysqli offer 10-30% cost savings.

How do I file a complaint with Ohio regulators?
Contact Ohio Department of Insurance at 1-800-686-1526. File complaints about improper denials, delayed appeals, or procedural violations. ODI can investigate and order corrective action.

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters against plan policies and crafting evidence-based appeals. Our platform identifies the specific denial basis and generates targeted rebuttals that align with payer criteria, improving approval rates for specialty medications like Ultomiris.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult your healthcare provider and insurance representative for personalized guidance. For questions about Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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