By Counterforce Health Team in Ultomiris (ravulizumab) —

How to Get Ultomiris (ravulizumab) Covered by Cigna in Washington: Forms, Appeals, and Patient Rights

Answer Box: Quick Path to Ultomiris Coverage

To get Ultomiris (ravulizumab) covered by Cigna in Washington: Your doctor submits a prior authorization using Cigna's Ultomiris PA form via CoverMyMeds portal or fax (855) 840-1678. Include diagnosis-specific documentation (anti-AChR antibodies for gMG, anti-AQP4 for NMOSD), prior therapy failures, and specialist consultation notes. If denied, file internal appeals within 180 days, then request external review through Washington's IRO process within 60 days. Contact Washington's Office of Insurance Commissioner at 1-800-562-6900 for assistance.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Enrollment with Accredo
  5. Appeals Process: Internal to External Review
  6. Washington State Consumer Protection
  7. Cost Support and Patient Assistance
  8. FAQ: Common Questions

Verify Your Plan and Find the Right Forms

Before starting your Ultomiris coverage request, confirm your Cigna plan details through the myCigna app or member services number on your ID card. Cigna typically manages specialty drugs like Ultomiris through Express Scripts and requires fulfillment via Accredo specialty pharmacy.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications Cigna PA Form
Formulary Status Specialty tier (varies by plan) Check myCigna portal
Step Therapy May require eculizumab trial first Plan-specific
Specialty Pharmacy Accredo required Cigna Specialty Pharmacy
Appeals Deadline 180 days for internal appeals Cigna Appeals Process

Prior Authorization Forms and Requirements

Cigna requires specific documentation for Ultomiris approval, varying by your diagnosis. Download the current Ultomiris prior authorization form and ensure all sections are completed.

Diagnosis-Specific Requirements

For Generalized Myasthenia Gravis (gMG):

  • Neurologist consultation confirmation
  • Anti-AChR antibody positive test results
  • Documentation of prior/current pyridostigmine use (or contraindication/intolerance)
  • Trial of ≥2 immunosuppressants for ≥1 year (azathioprine, cyclosporine, mycophenolate, methotrexate, tacrolimus, cyclophosphamide) or documentation of inadequate response

For Neuromyelitis Optica Spectrum Disorder (NMOSD):

  • Neurologist consultation confirmation
  • Anti-aquaporin-4 antibody positive results
  • Clinical notes supporting diagnosis

For Atypical Hemolytic Uremic Syndrome (aHUS):

  • Nephrologist consultation confirmation
  • Exclusion of STEC-HUS (Shiga toxin-producing E. coli)
  • Complement pathway testing results
Tip: Attach all supporting lab results, imaging, and detailed clinical notes. Incomplete submissions are the most common reason for initial denials.

Submission Portals and Methods

Preferred Submission Methods

  1. Online Portal (Fastest): CoverMyMeds or SureScripts through your EHR system
  2. Fax: (855) 840-1678 for standard requests
  3. Urgent Requests: Call (800) 882-4462 and fax immediately with "URGENT" marking

Required Information for All Submissions

  • Patient demographics (name, phone, weight in kg, ZIP code)
  • Complete diagnosis with ICD-10 codes
  • Requested dose, frequency, and duration
  • Prescriber signature and attestation
  • Pharmacy preference (specify Accredo for Cigna plans)

Specialty Pharmacy Enrollment with Accredo

If your Ultomiris prior authorization is approved, Cigna requires fulfillment through Accredo specialty pharmacy. Here's how to get enrolled:

Step-by-Step Enrollment Process

  1. Download Enrollment Form: Get the Accredo Prescription & Enrollment Form
  2. Complete Patient Information: Include insurance details, delivery preferences, and emergency contacts
  3. Submit via Multiple Channels:
    • ePrescribe to NCPDP ID: 4436920
    • Fax: 833-951-1686
    • Phone: 866-759-1557

Patient Support Services

Call 877-826-7657 (Mon-Fri 7am-10pm CST, Sat 7am-4pm CST) for:

  • Account setup and prescription tracking
  • Home delivery coordination
  • Financial assistance programs
  • Clinical support and injection training
Note: Create your patient account at MyAccredoPatients.com to track shipments and manage refills online.

Appeals Process: Internal to External Review

If Cigna denies your Ultomiris request, Washington state provides strong consumer protections through a structured appeals process.

Internal Appeals (First Step)

Timeline: File within 180 days of denial notice Forms: Cigna Customer Appeal Request Form Submission:

  • Mail: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Fax: 1-866-567-2474 (mark "EXPEDITED" if urgent)

Required Documentation for Appeals

  • Original denial letter and claim details
  • Medical records supporting medical necessity
  • Physician statement explaining why Ultomiris is required
  • Evidence of failed prior therapies
  • Relevant clinical guidelines or FDA labeling

External Review Through Washington IRO

If internal appeals are unsuccessful, Washington residents can request an Independent Review Organization (IRO) evaluation.

Key Steps:

  1. Eligibility: Available after exhausting internal appeals for fully-insured plans
  2. Timeline: Submit written request to Cigna within 60 days of final internal denial
  3. Process: Cigna assigns certified IRO; you have 5 business days to submit additional information
  4. Decision Timeline: 20 days for standard review, 72 hours for expedited cases

Contact Information:

Important: IRO decisions are binding on Cigna. If the IRO overturns the denial, Cigna must provide coverage.

Washington State Consumer Protection

Washington state offers robust protections for patients facing insurance denials, particularly for rare disease medications like Ultomiris.

State Resources and Support

Washington Office of Insurance Commissioner:

Consumer Rights in Washington:

  • External review for medical necessity denials
  • Expedited review for urgent cases (72-hour decisions)
  • Protection against surprise billing
  • Access to independent medical experts through IRO process

When to Contact the OIC

  • Cigna fails to assign an IRO within 5 days
  • Procedural violations during appeals
  • Questions about your rights under Washington insurance law
  • Need for template appeal letters or guidance

Cost Support and Patient Assistance

Ultomiris costs approximately $474,000-$569,000 annually, making financial assistance crucial for most patients.

Available Support Programs

Manufacturer Assistance:

  • Alexion Access Navigator - copay assistance and case management
  • Financial counselors available through Accredo
  • Patient assistance programs for qualifying uninsured/underinsured patients

Additional Resources:

  • State pharmaceutical assistance programs
  • Disease-specific foundations and grants
  • Hospital charity care programs
  • Social services coordination through specialty pharmacy

FAQ: Common Questions

How long does Cigna prior authorization take for Ultomiris? Standard PA decisions typically take 72 hours to 5 business days. Expedited reviews (when health is at risk) are processed within 24-72 hours.

What if Ultomiris isn't on my Cigna formulary? Request a formulary exception by documenting that formulary alternatives are ineffective or contraindicated.

Can I get expedited appeals in Washington? Yes, if your health could be seriously jeopardized by delays. Mark requests "EXPEDITED" and provide medical documentation of urgency.

Does step therapy apply if I've tried eculizumab outside Washington? Yes, document prior therapies from any location. Include medical records, dates of treatment, and reasons for discontinuation.

What happens if the IRO upholds Cigna's denial? The IRO decision is final for the appeals process, but you may contact the OIC for additional guidance or consider legal options.

How do I transfer from another specialty pharmacy to Accredo? Accredo can coordinate transfers automatically for eligible refills. Call 877-826-7657 with your current pharmacy information and prescription details.

Counterforce Health helps patients and clinicians navigate complex insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer requirements, pulling the right clinical evidence and procedural documentation to improve approval rates. Learn more at counterforcehealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For personalized assistance with appeals and coverage issues, consider working with Counterforce Health or contacting the Washington Office of Insurance Commissioner.

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