By Counterforce Health Team in Uplizna (inebilizumab) —

How to Get Uplizna (Inebilizumab) Covered by Cigna in Texas: Complete Guide to Prior Authorization, Appeals, and Approval Strategies

Answer Box: Getting Uplizna (Inebilizumab) Covered by Cigna in Texas

Uplizna (inebilizumab) requires prior authorization from Cigna and is typically covered for AQP4-positive NMOSD when prescribed by a neurologist with documented step therapy. Your fastest path: (1) Have your neurologist submit a prior authorization through CoverMyMeds or Cigna's provider portal with AQP4-IgG test results and evidence of failed corticosteroids/rituximab, (2) Expect 3-5 business days for standard review (24-48 hours if urgent), (3) If denied, file an internal appeal within 180 days using Cigna's appeal forms. Texas law guarantees external review through an Independent Review Organization if internal appeals fail.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Medical Necessity Criteria
  4. Timeline and Urgency
  5. Step Therapy Requirements
  6. Costs and Financial Assistance
  7. Denials and Appeals in Texas
  8. Specialty Pharmacy Requirements
  9. Renewal and Continuation
  10. FAQ: Common Questions

Coverage Basics

Is Uplizna covered by Cigna? Yes, but with restrictions. Uplizna (inebilizumab) is classified as a specialty medication requiring prior authorization for all Cigna plans. It's not on standard formularies, meaning you'll need a formulary exception along with medical necessity approval.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all plans Cigna PA Forms
Formulary Status Non-formulary (exception needed) Plan formulary documents
Step Therapy Failed corticosteroids + rituximab/immunosuppressants Medical policy IP_0062
Specialty Pharmacy Accredo mandatory Accredo Specialty Pharmacy
Site of Care Outpatient infusion center J-code J1823 billing
Texas Appeals 180-day deadline Texas DOI External Review

Which Cigna plans cover Uplizna? All Cigna health plans (HMO, PPO, EPO, POS) can cover Uplizna when medical necessity criteria are met. Medicare Advantage plans follow similar requirements but may have different cost-sharing structures.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • AQP4-IgG antibody test results (positive required for NMOSD)
    • Neurology consultation notes confirming NMOSD diagnosis
    • Documentation of prior treatments and outcomes
    • Complete medical history and current medications
  2. Submit Electronic Prior Authorization (Prescriber)
  3. Route Through Accredo Specialty Pharmacy (Prescriber)
    • Prescription must be sent to Accredo (1-866-759-1557)
    • NCPDP ID: 4436920
    • Accredo coordinates with Cigna for PA processing
  4. Await Determination (3-5 business days standard)
    • Check status via Cigna provider portal
    • Expedited review available for urgent cases (24-48 hours)
  5. Coordinate Infusion Site (If Approved)
    • Schedule at outpatient infusion center
    • Verify J-code J1823 billing capabilities
    • Confirm 90-minute infusion time availability
Tip: Submit PA requests electronically whenever possible. Electronic submissions typically process faster than fax or mail submissions.

Medical Necessity Criteria

Clinician Corner: Medical Necessity Letter Checklist

Your neurologist's letter must include:

Diagnosis Requirements:

Prior Treatment Documentation:

  • Failed or intolerant to corticosteroids (prednisone/methylprednisolone)
  • Failed or intolerant to rituximab OR other immunosuppressants (azathioprine, mycophenolate)
  • Specific dates, doses, duration, and reasons for discontinuation

Clinical Rationale:

  • Relapse frequency and severity
  • Disability progression (EDSS scores if available)
  • Why Uplizna is medically appropriate over alternatives
  • Reference to FDA labeling and clinical guidelines

Safety Screening:

  • Hepatitis B screening results (required before treatment)
  • Vaccination status and infection risk assessment
  • Contraindication documentation for alternative therapies

Timeline and Urgency

Standard vs. Expedited Review

Standard Review Timeline:

  • Commercial plans: 5 business days maximum
  • Medicare Advantage: 72 hours maximum
  • Submit complete documentation to avoid delays

Expedited Review (NMOSD Relapse Emergency):

  • Commercial plans: 48 hours
  • Medicare Advantage: 24 hours
  • How to request: Mark PA as "urgent" and call Cigna immediately at 1-800-882-4462
  • Document acute relapse and need for immediate treatment
Note: For NMOSD relapses requiring immediate treatment, your neurologist should also consider bridging therapy (corticosteroids) while awaiting Uplizna approval.

Step Therapy Requirements

Most Cigna plans require documented failure, intolerance, or contraindication to first-line treatments before approving Uplizna:

Required Step Therapy

Treatment Category Specific Requirements Documentation Needed
Corticosteroids Must try prednisone or IV methylprednisolone Dates, doses, response, side effects
B-cell Depletion Rituximab preferred (if no contraindication) Treatment dates, infusion records, efficacy
Oral Immunosuppressants Azathioprine OR mycophenolate Duration of trial, lab monitoring, outcomes

Step Therapy Exceptions

You may skip step therapy if:

  • Medical contraindications exist (documented allergies, drug interactions)
  • Previous treatment within 12 months (with records)
  • Urgent clinical situation where delay would be harmful

Counterforce Health helps patients and clinicians navigate complex step therapy requirements by analyzing payer policies and crafting targeted appeals that address specific coverage criteria.

Costs and Financial Assistance

Understanding Your Costs

Uplizna Pricing: Approximately $140,248.50 per 300mg dose (list price)

  • Year 1: ~$420,000 (3 doses)
  • Maintenance: ~$280,000 annually (2 doses)

Cigna Cost-Sharing:

  • Specialty tier copay/coinsurance applies (typically 20-50% coinsurance)
  • Review your Summary of Benefits and Coverage for exact amounts
  • Annual out-of-pocket maximums provide cost protection

Financial Assistance Options

Manufacturer Support:

  • Amgen By Your Side Program offers copay assistance for eligible commercial insurance patients
  • Income and insurance eligibility requirements apply

Texas State Resources:

  • Contact Texas Department of Insurance Consumer Help Line: 1-800-252-3439
  • Office of Public Insurance Counsel (OPIC): 1-877-611-6742

Denials and Appeals in Texas

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Not AQP4-positive Submit lab results showing AQP4-IgG seropositivity
Insufficient specialist involvement Provide neurology consultation notes and credentials
Missing step therapy Document prior treatments with dates, doses, outcomes
Site of care issues Confirm outpatient infusion center capabilities
Missing HBV screening Submit hepatitis B test results

Texas Appeals Process

Internal Appeal (First Level):

  • Deadline: 180 days from denial notice
  • Forms: Cigna Medical Appeal Request
  • Address: Cigna Healthcare Inc. National Appeals Unit
    PO Box 188011
    Chattanooga, TN 37422
  • Timeline: 60 days for decision (faster for urgent cases)

External Review (Independent Review Organization):

  • Eligibility: After internal appeal denial
  • Deadline: 180 days from final internal denial
  • Process: Texas Department of Insurance coordinates external review
  • Contact: TDI External Review Program
  • Timeline: 20 days for standard cases, 5 days for urgent cases
Texas Advantage: Texas law provides robust external review rights. The Independent Review Organization's decision is binding on Cigna if they overturn the denial.

Specialty Pharmacy Requirements

Mandatory Accredo Dispensing: Cigna requires Uplizna to be dispensed through Accredo Specialty Pharmacy unless medically inappropriate.

Accredo Contact Information:

  • Phone: 1-866-759-1557
  • Fax: 888-302-1028
  • NCPDP ID: 4436920

Coordination Process:

  1. Prescriber sends prescription to Accredo
  2. Accredo contacts patient for intake and insurance verification
  3. Accredo coordinates with infusion site for delivery
  4. Medication typically delivered 5-10 business days after approval

Renewal and Continuation

When to Reauthorize

  • Initial authorization: Typically 6-12 months
  • Renewal: Every 8-12 months thereafter
  • Submit renewal 30-60 days before expiration

Renewal Requirements

Clinical Response Documentation:

  • Reduction in relapse frequency
  • Stabilization of neurological function
  • EDSS scores or other functional measures
  • Absence of unacceptable side effects

Ongoing Safety Monitoring:

  • Regular laboratory monitoring results
  • Infection screening updates
  • Vaccination status documentation

When navigating complex renewal requirements, Counterforce Health assists healthcare providers in compiling comprehensive renewal documentation that meets payer-specific criteria and reduces the risk of coverage interruption.

FAQ: Common Questions

Q: How long does Cigna prior authorization take in Texas? A: Standard review takes 3-5 business days for commercial plans, 72 hours for Medicare Advantage. Expedited review (for urgent cases) takes 24-48 hours.

Q: What if Uplizna is non-formulary on my Cigna plan? A: You'll need both a formulary exception and prior authorization. Your neurologist must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Q: Can I request an expedited appeal in Texas? A: Yes. If you're experiencing an NMOSD relapse or your health could be jeopardized by delays, request expedited internal and external review processes.

Q: Does step therapy apply if I previously tried treatments outside Texas? A: Yes. Document all prior treatments regardless of where they occurred. Complete medical records showing previous failures should satisfy step therapy requirements.

Q: What happens if my appeal is denied? A: Texas law guarantees external review by an Independent Review Organization. Their decision is binding on Cigna if they approve coverage.

Q: Can I get Uplizna at any infusion center? A: The infusion center must be in-network with Cigna and capable of billing J-code J1823. Verify capabilities before scheduling.

Q: How much will I pay out-of-pocket? A: This depends on your specific plan's specialty drug cost-sharing. Check your Summary of Benefits and Coverage or call Cigna member services for exact amounts.

Q: What if I can't afford my copay/coinsurance? A: Apply for manufacturer copay assistance through the Amgen By Your Side Program. Also explore patient foundation grants and Texas state pharmaceutical assistance programs.

From Our Advocates

We've seen many NMOSD patients initially denied for Uplizna due to incomplete step therapy documentation. The key is working with your neurologist to compile a comprehensive treatment history—even treatments from years ago matter. One patient we helped had tried rituximab five years earlier at a different hospital, but those records made all the difference in getting approval. Don't assume your doctor has all your records; actively gather documentation from all previous providers.

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 plan for specific coverage decisions. Coverage policies and requirements may change; verify current information with official sources.

For additional support navigating insurance coverage challenges, Counterforce Health provides specialized assistance to patients, clinicians, and specialty pharmacies in turning insurance denials into successful appeals through evidence-based advocacy and payer-specific expertise.

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