By Counterforce Health Team in Vitrakvi (larotrectinib) —

How to Get Vitrakvi (Larotrectinib) Covered by Cigna in Michigan: Complete PA Guide and Appeal Scripts

Answer Box: Getting Vitrakvi Covered by Cigna in Michigan

Vitrakvi (larotrectinib) requires prior authorization from Cigna for NTRK fusion-positive solid tumors that are metastatic or unresectable. Submit PA via CoverMyMeds or Evicore with molecular pathology report confirming NTRK fusion, oncologist prescription, and tumor staging documentation. If denied, Michigan residents have 127 days to file external review with DIFS. First step today: Verify your Cigna plan covers specialty drugs through Accredo at myCigna.com and gather NTRK fusion test results.

Table of Contents

Plan Types & Coverage Implications

Cigna offers multiple plan types in Michigan, each affecting how Vitrakvi coverage works:

Commercial Plans: Most Cigna members in Michigan have employer-sponsored coverage with specialty drug benefits through Express Scripts/Accredo. These plans typically require prior authorization for high-cost oncology medications.

Medicare Advantage: Cigna's Medicare plans in Michigan follow CMS guidelines but may have additional utilization management. Prior authorization decisions must be made within 72 hours for non-urgent requests.

Individual Marketplace Plans: ACA-compliant plans sold through Healthcare.gov include essential health benefits but may have higher cost-sharing for specialty tiers.

Note: Michigan's relatively low uninsured rate (4.5-6%) means most residents have coverage, but plan design varies significantly between employers and individual policies.

Formulary Status & Tier Placement

Vitrakvi is covered by Cigna as a specialty oncology drug under prior authorization, typically placed in Tier 4 or specialty tier with higher cost-sharing.

Coverage Criteria Summary:

  • FDA-approved indication for NTRK gene fusion-positive solid tumors
  • Tumor must be metastatic, locally advanced, or unresectable
  • Surgical resection would likely cause severe morbidity
  • Confirmed by validated molecular pathology testing

Related NTRK Inhibitors (similar criteria apply):

  • Rozlytrek (entrectinib): Also covers ROS1-positive NSCLC
  • Augtyro (repotrectinib): For patients ≥12 years, requires progression after prior treatment

Prior Authorization Requirements

Cigna requires comprehensive documentation for Vitrakvi approval:

Required Documentation Checklist

  • NTRK Fusion Test Results: Molecular pathology report with specific fusion partner
  • Prescriber Credentials: Board-certified oncologist preferred
  • Tumor Staging: Imaging showing metastatic/unresectable disease
  • Prior Therapy Documentation: If plan requires step therapy
  • Medical Necessity Letter: ICD-10 codes, dosing plan, clinical rationale

Electronic Submission Options

  1. CoverMyMeds: Free portal with real-time status updates
  2. Evicore by Evernorth: Select "Pharmacy Drug (Express Scripts Coverage)"
  3. Surescripts CompletEPA: Integrated with many EHR systems

Timeline: Non-urgent decisions within 72 hours; urgent/exigent within 24 hours.

Specialty Pharmacy Network

Cigna requires Vitrakvi to be dispensed through Accredo Specialty Pharmacy for most plans.

Accredo Enrollment Process

  1. Call Accredo: 877-826-7657 after PA approval
  2. Complete Enrollment: Download forms from Accredo's prescriber portal
  3. Submit Documentation: Fax to 888-302-1028 with prescription and clinical data
  4. Track Orders: Use MyAccredoPatients.com or myCigna app

Required Information:

  • Patient demographics and emergency contacts
  • Prescriber NPI and license information
  • Clinical data (ICD-10, weight, allergies, concurrent medications)
  • Delivery preferences (home or office)

Step-by-Step Approval Process

Fastest Path to Vitrakvi Coverage

  1. Verify Benefits (Patient/Clinic Staff)
    • Log into myCigna.com to confirm specialty coverage
    • Check formulary status and tier placement
    • Timeline: 5-10 minutes
  2. Order NTRK Testing (Oncologist)
    • Use FDA-approved companion diagnostic
    • Document fusion partner and testing methodology
    • Timeline: 1-2 weeks for results
  3. Submit Prior Authorization (Clinic Staff)
  4. Enroll with Accredo (Upon Approval)
    • Call 877-826-7657 to initiate
    • Complete enrollment forms
    • Timeline: 1-2 business days
  5. Coordinate Delivery (Patient/Accredo)
    • Arrange home or office delivery
    • Set up refill reminders
    • Timeline: 2-3 days shipping

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
No NTRK fusion documented Submit molecular pathology report Lab report with fusion partner and testing method
Tumor appears resectable Provide staging and surgical consultation Imaging, oncology note on unresectability
Non-oncologist prescriber Transfer to board-certified oncologist Updated prescription with oncologist credentials
Step therapy not completed Document contraindications or failures Prior therapy records, intolerance documentation
Experimental/investigational Clarify FDA-approved indication Copy of FDA label for NTRK fusion-positive tumors
From Our Advocates: "We've seen Vitrakvi approvals succeed when the molecular pathology report clearly states both the NTRK gene involved and the specific fusion partner. Generic 'NTRK-positive' results often trigger denials, while detailed reports like 'NTRK1-TPM3 fusion detected via RNA sequencing' typically get approved on first submission."

Michigan Appeals Process

If Cigna denies your Vitrakvi prior authorization, Michigan provides robust appeal rights:

Internal Appeals (Required First Step)

  • Timeline: Submit within 180 days of denial
  • Process: Use Cigna's provider portal or call member services
  • Decision: 10 days standard, 72 hours urgent
  • Required: Clinical rationale, additional evidence, peer-reviewed literature

Michigan External Review

After exhausting internal appeals, Michigan residents can request independent review:

  • Timeline: 127 days after final internal denial
  • Cost: Free to patients
  • Process: Submit request to Department of Insurance and Financial Services (DIFS)
  • Decision: 60 days maximum, often faster
  • Expedited: 72 hours with physician letter stating health jeopardy

DIFS Contact Information:

Required Documentation for Appeals

  • Original denial letter from Cigna
  • All medical records supporting medical necessity
  • Physician statement of clinical rationale
  • Relevant clinical guidelines (NCCN, FDA label)
  • Patient impact statement (optional but helpful)

Cost-Share Considerations

Vitrakvi's annual cost approaches $394,000, making cost-sharing a significant concern even with insurance coverage.

Typical Cigna Cost-Sharing:

  • Specialty Tier: 25-40% coinsurance after deductible
  • Out-of-Pocket Maximum: $8,700 individual/$17,400 family (2024 ACA limits)

Financial Assistance Options:

  • Bayer's TRAK Assist Program: Copay support for eligible commercial patients
  • Patient Access Network Foundation: Grants for rare cancer medications
  • Accredo Patient Assistance: Financial counseling and foundation applications

Counterforce Health helps patients navigate these complex financial assistance programs while managing the prior authorization process, ensuring all available support is maximized before patients face significant out-of-pocket costs.

Frequently Asked Questions

How long does Cigna prior authorization take for Vitrakvi in Michigan? Standard requests receive decisions within 72 hours; urgent requests within 24 hours. Electronic submissions via CoverMyMeds are typically fastest.

What if Vitrakvi is non-formulary on my Cigna plan? Request a formulary exception through the same prior authorization process. Include clinical rationale why formulary alternatives aren't appropriate for NTRK fusion-positive tumors.

Can I request expedited appeal in Michigan? Yes. Michigan offers expedited external review (72-hour decision) if your physician provides a letter stating that delay would seriously jeopardize your health.

Does step therapy apply to Vitrakvi for NTRK fusion-positive tumors? Step therapy requirements vary by plan, but exceptions are common for rare genetic mutations like NTRK fusions due to limited treatment alternatives.

What happens if I switch Cigna plans mid-treatment? Michigan law may provide continuity protections. Contact DIFS if your new plan doesn't honor existing prior authorizations.

Who can help me navigate the appeals process in Michigan? Counterforce Health specializes in turning insurance denials into successful appeals using evidence-based approaches tailored to each payer's specific requirements.

What counts as medical necessity for Vitrakvi? Cigna defines medical necessity as NTRK fusion-positive solid tumors that are metastatic, locally advanced, or where resection would cause severe morbidity.

Can my family doctor prescribe Vitrakvi? While not explicitly required, Cigna policies favor board-certified oncologists for specialty cancer medications. Primary care prescriptions may face additional scrutiny.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with your specific Cigna plan and consult with your healthcare provider about treatment decisions. For personalized assistance with prior authorizations and appeals, consider consulting with healthcare coverage advocates who specialize in insurance navigation.

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