By Counterforce Health Team in Vigabatrin (generic; Sabril originator Lundbeck) —

How to Get Vigabatrin Covered by Cigna in Washington: Prior Authorization Forms, Appeals, and REMS Requirements

Quick Answer: To get Vigabatrin covered by Cigna in Washington, you need: (1) REMS program enrollment for patient, prescriber, and pharmacy, (2) baseline vision testing by an ophthalmologist, (3) prior authorization submission with diagnosis codes and failed therapy documentation. Start by confirming REMS enrollment status—this is the most common delay. Appeals go through Cigna's internal process first, then Washington's Independent Review Organization (IRO) if denied.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Plan
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You Need More Information
  7. If Your Request Is Denied
  8. Renewal and Re-authorization
  9. Common Denial Reasons & Solutions
  10. Washington State Appeals Process
  11. Frequently Asked Questions
  12. Printable Checklist

What This Guide Covers

This guide helps patients and clinicians navigate Cigna's prior authorization process for Vigabatrin (including generic versions and brand name Sabril) in Washington state. Vigabatrin is an FDA-approved medication for infantile spasms in children 1 month to 2 years old and refractory complex partial seizures in patients who've failed other antiepileptic drugs.

Who this helps: Patients with Cigna coverage, their caregivers, prescribing physicians, and specialty pharmacies managing Vigabatrin therapy.

Expected outcome: With proper documentation and REMS enrollment, most medically appropriate requests get approved within 72 hours to 7 business days. If denied initially, Washington's robust appeals process provides multiple pathways to coverage.

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and creating point-by-point rebuttals aligned to each plan's specific requirements.

Before You Start: Verify Your Plan

Confirm Your Cigna Plan Type

  • Commercial plans: Most require prior authorization through Express Scripts/Accredo
  • Medicare Advantage: May have different formulary requirements
  • Medicaid managed care: Check if your plan uses Cigna or another pharmacy benefit manager

Check Formulary Status

Vigabatrin typically requires prior authorization for both generic and brand versions. Contact Cigna member services at the number on your insurance card to confirm:

  • Formulary tier placement
  • Whether step therapy requirements apply
  • Preferred pharmacy network for specialty medications

Verify In-Network Status

Ensure your prescribing physician and dispensing pharmacy are in-network. Specialty pharmacies like Accredo often handle Vigabatrin due to REMS requirements.

Gather Required Documentation

Essential Clinical Information

Diagnosis Documentation:

  • Infantile spasms: ICD-10 code G40.822 (non-intractable infantile spasms without status epilepticus)
  • Refractory complex partial seizures: Appropriate epilepsy ICD-10 codes with documentation of failed prior therapies

Prior Therapy Records:

  • List of previously tried antiepileptic drugs
  • Documentation of inadequate response or intolerance
  • Dates and duration of each trial

Clinical Notes:

  • Current seizure frequency and type
  • Treatment goals and expected outcomes
  • Weight and dosing calculations

Vision Testing Requirements

Baseline ophthalmology examination is mandatory before starting Vigabatrin:

  • Must be completed within 90 days of therapy start or no later than 4 weeks after initiation
  • Requires comprehensive eye exam by an ophthalmologist
  • Visual field testing using Humphrey 120 point, Octopus 07, or Goldmann perimetry
  • For pediatric patients unable to cooperate: electroretinography (ERG) or visual evoked potentials (VEPs)

REMS Program Enrollment

All parties must enroll in the Vigabatrin REMS Program before any prescription can be filled:

Prescriber requirements:

  • Complete REMS certification training
  • Enroll in the program online or by fax
  • Provide patient counseling on risks and benefits

Patient/caregiver requirements:

  • Review "What You Need to Know About Vigabatrin Treatment" guide
  • Sign Patient/Parent/Legal Guardian–Physician Agreement Form (PPLG)
  • Understand vision monitoring requirements

Pharmacy requirements:

  • REMS certification for dispensing
  • Staff training completion
  • Ongoing compliance monitoring

Submit Your Prior Authorization Request

Submission Methods

Provider Portal: Most efficient method through Cigna's online provider portal Fax: Submit to Cigna prior authorization fax line (verify current number with member services) Phone: For urgent cases, call Cigna clinical prior authorization line

Clean Request Packet Checklist

✓ Completed prior authorization form ✓ Prescriber attestation of medical necessity ✓ REMS enrollment confirmation for all parties ✓ Baseline vision testing results ✓ Diagnosis with ICD-10 codes ✓ Prior therapy documentation with dates and outcomes ✓ Current clinical notes with seizure frequency ✓ Dosing rationale based on weight/age

Tip: Submit all required documents together to avoid delays. Incomplete submissions are a leading cause of prior authorization rejections.

Follow-Up and Timelines

Expected Timelines

Initial review: 72 hours to 7 business days for standard requests Final determination: Up to 15 business days total Expedited review: 24-72 hours for urgent medical situations

When to Follow Up

  • Call after 3 business days if no acknowledgment received
  • Request reference numbers for all communications
  • Ask specific questions: "What additional information is needed?" rather than "What's the status?"

Sample Follow-Up Script

"This is [your name] calling about prior authorization request [reference number] for Vigabatrin submitted on [date]. Can you tell me if any additional clinical information is needed to complete the review?"

If You Need More Information

Common Additional Requests

Medical necessity clarification:

  • Detailed treatment history with specific drug names and trial durations
  • Documentation of seizure frequency before and during previous treatments
  • Specialist consultation notes confirming refractory status

Safety monitoring documentation:

  • Baseline laboratory values if relevant
  • Confirmation of vision monitoring plan
  • Patient/caregiver understanding of REMS requirements

Responding Effectively

Submit requested information promptly with clear cover letter explaining how each document addresses the specific question raised. Reference the original prior authorization number in all correspondence.

If Your Request Is Denied

Understanding Denial Letters

Common denial codes include:

  • Medical necessity: Insufficient documentation of failed prior therapies
  • REMS non-compliance: Missing enrollment or vision testing
  • Age/indication mismatch: Use outside FDA-approved parameters
  • Formulary restrictions: Step therapy not completed

First-Level Appeal Options

Internal appeal: Submit within 180 days of denial notice Peer-to-peer review: Request physician-to-physician discussion Expedited appeal: For urgent medical situations

Renewal and Re-authorization

Re-authorization Timeline

Most plans require re-authorization every 3-6 months for Vigabatrin, with specific windows:

  • Infantile spasms: 2-4 weeks initially, then longer intervals if beneficial
  • Complex partial seizures: ~3 months initially

Documentation for Renewal

  • Updated seizure logs showing treatment response
  • Continued vision monitoring results
  • Assessment of ongoing medical necessity
  • Any medication adjustments or side effects
Note: Calendar renewal dates 30 days in advance to ensure continuous coverage.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
REMS enrollment missing Complete enrollment for all parties REMS confirmation numbers
No baseline vision testing Schedule ophthalmology exam Vision assessment report
Insufficient prior therapy documentation Provide detailed treatment history Pharmacy records, clinic notes
Off-label use concern Submit literature supporting indication FDA labeling, guidelines
Step therapy not met Document failures of preferred agents Treatment timelines, outcomes

Washington State Appeals Process

Internal Appeals with Cigna

Timeline: Must file within 180 days of denial Process: Submit written appeal with additional clinical documentation Response time: 30 days for standard appeals, 72 hours for expedited

External Review Through IRO

If Cigna denies your internal appeal, Washington law provides independent review:

Eligibility: Available after completing internal appeals process Timeline: Must request within 60 days of final internal denial Process: Independent Review Organization (IRO) assigned through Washington Office of Insurance Commissioner Cost: No cost to patient Decision: Binding on Cigna if approved

How to request: Contact Washington Office of Insurance Commissioner at 1-800-562-6900 or submit request directly to Cigna, who will forward to the state IRO system.

Standard timeline: 20 days for fully-insured plans, 45 days for self-insured Expedited timeline: 72 hours for urgent cases

From our advocates: We've seen many Vigabatrin denials overturned on appeal when families submitted comprehensive REMS documentation and detailed seizure logs showing inadequate response to prior medications. The key is demonstrating both medical necessity and safety protocol compliance. This represents a composite of successful appeal strategies, not guaranteed outcomes.

Frequently Asked Questions

How long does Cigna prior authorization take for Vigabatrin in Washington? Standard review takes 3-7 business days, but REMS enrollment delays can extend this to 2-3 weeks if not completed beforehand.

What if Vigabatrin is non-formulary on my plan? You can request a formulary exception with clinical documentation showing medical necessity and failure of preferred alternatives.

Can I request an expedited appeal if my child's seizures are worsening? Yes, Washington allows expedited appeals for urgent medical situations with 72-hour decision timelines.

Does step therapy apply if we've already tried other medications outside Washington? Treatment history from other states counts toward step therapy requirements—submit all relevant medical records.

What happens if vision testing shows problems during treatment? Your doctor will weigh the risks and benefits. Some patients continue with closer monitoring, while others may need to discontinue.

How much does Vigabatrin cost without insurance in Washington? Generic versions cost approximately $4,557 for 100×500mg tablets, while brand Sabril can exceed $19,000 for the same quantity.

Can specialty pharmacies help with the prior authorization process? Yes, Accredo and other specialty pharmacies often assist with PA submissions and REMS enrollment coordination.

What if my employer plan is self-insured? Self-insured plans may not be subject to Washington state insurance laws, but many voluntarily follow similar appeal processes.

Printable Checklist

Before Submitting PA Request:

  • Confirm Cigna plan type and formulary status
  • Complete REMS enrollment (patient, prescriber, pharmacy)
  • Schedule baseline vision testing
  • Gather prior therapy documentation
  • Obtain current clinical notes with seizure frequency

During PA Process:

  • Submit complete packet with all required documents
  • Follow up within 3 business days
  • Respond promptly to requests for additional information
  • Document all reference numbers and communication dates

If Denied:

  • Review denial reason carefully
  • Gather additional supporting documentation
  • Submit internal appeal within 180 days
  • Consider peer-to-peer review request
  • Know your rights to external IRO review in Washington

This guide provides educational information and is not medical advice. For specific medical questions, consult your healthcare provider. For insurance coverage disputes, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

Sources & Further Reading

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