By Counterforce Health Team in Xembify (immune globulin, SC) —

How to Get Xembify (Immune Globulin, SC) Covered by Cigna in Washington: Complete Guide with Forms and Appeals

Answer Box: Getting Xembify Covered by Cigna in Washington

Fastest path to approval: Your doctor submits prior authorization through CoverMyMeds or faxes Cigna's specialty drug PA form with clinical documentation showing primary immunodeficiency diagnosis, low immunoglobulin levels, and infection history. If denied, file internal appeals within 180 days, then request external review through Washington's Independent Review Organization. Start today: Have your doctor check Cigna's formulary status and gather your immunodeficiency labs and infection records.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Forms You Need
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup
  5. Support Phone Numbers
  6. Appeals Process in Washington
  7. External Review and State Resources
  8. Common Denial Reasons and Solutions
  9. FAQ

Start Here: Verify Your Plan and Coverage

Before pursuing Xembify coverage, confirm your specific Cigna plan details. Xembify (immune globulin subcutaneous, 20%) requires prior authorization for virtually all insurance plans due to its specialty status and high cost ($196-$1,889 per vial).

First steps:

  1. Log into your myCigna portal to check if Xembify is on your formulary
  2. Verify your plan uses Express Scripts or Accredo for specialty medications
  3. Confirm your primary immunodeficiency diagnosis is documented with ICD-10 codes
Note: Most Cigna plans in Washington manage specialty drugs through Express Scripts/Accredo, which requires separate coordination beyond standard pharmacy benefits.

Forms You Need

Prior Authorization Forms

Your prescriber must submit the Cigna Commercial Drug Prior Authorization Form available through:

Required information includes:

  • Patient demographics and Cigna ID
  • Primary immunodeficiency diagnosis with ICD-10 codes
  • Immunoglobulin levels (IgG, IgA, IgM)
  • History of recurrent infections
  • Previous IVIG or SCIG treatments tried/failed
  • Dosing calculation based on weight

Formulary Exception Request

If Xembify is non-formulary on your plan, your doctor can request a formulary exception using Cigna's exception form. The physician must certify that:

  • Formulary alternatives were ineffective or detrimental
  • Step-therapy drugs are contraindicated
  • You're achieving positive outcomes on Xembify that can't be replicated

Review timelines: 1-3 business days for standard requests, 24 hours for expedited reviews.

Submission Portals and Methods

Electronic Prior Authorization (Preferred)

Fastest approval method:

  • CoverMyMeds: Primary portal for Cigna PA submissions
  • SureScripts: Alternative electronic submission
  • ExpressPAth: For Express Scripts-managed plans

Fax and Phone Backup

If electronic submission isn't possible:

  • Fax: Use the number on the specific PA form (varies by plan)
  • Phone: 1-800-882-4462 for Cigna prior authorization questions
Tip: Electronic submissions typically process within 24-72 hours, while fax submissions may take 5-7 business days.

Specialty Pharmacy Setup

Cigna Specialty Pharmacy Coordination

Key contact: 1-800-351-3606 (24/7 specialty pharmacy line)

Setup process:

  1. Cigna contacts your prescriber after PA approval
  2. Prescription transferred to specialty pharmacy (usually Accredo)
  3. Clinical consultation with specialty pharmacist
  4. Home delivery or clinic administration arranged
  5. Ongoing case management and refill coordination

Case management support: 1-877-505-3681 (Monday-Friday, 8 AM-7 PM EST) for complex therapy coordination.

Support Phone Numbers

Service Phone Number Hours Purpose
Cigna Member Services 1-800-244-6224 24/7 General coverage questions
Specialty Pharmacy 1-800-351-3606 24/7 Prescription transfers, SCIG coordination
Case Management 1-877-505-3681 M-F, 8 AM-7 PM EST Complex therapy support
Prior Authorization 1-800-882-4462 Business hours PA status and questions

Appeals Process in Washington

Internal Appeals with Cigna

Timeline: 180 days from denial to file internal appeal

Process:

  1. First-level appeal: Submit written request to Cigna appeals department
  2. Second-level appeal: If first appeal denied, request second review
  3. Expedited appeals: Available if health is at serious risk (24-hour decision)

Cigna Appeals Contact: 1-800-244-6224

Required Documentation for Appeals

  • Original denial letter
  • Complete medical records supporting immunodeficiency diagnosis
  • Lab results showing low immunoglobulin levels
  • Documentation of recurrent infections
  • Previous treatment failures or contraindications
  • Peer-reviewed literature supporting Xembify use
From our advocates: We've seen many Cigna immunoglobulin denials overturned when appeals include specific infection frequency data and clear documentation of why oral antibiotics or prophylaxis failed. The key is showing medical necessity through concrete clinical outcomes, not just lab values alone.

External Review and State Resources

Washington State External Review Process

After exhausting Cigna's internal appeals, Washington residents can request Independent Review Organization (IRO) review under RCW 48.43.535.

Process:

  1. Eligibility: Must complete all internal Cigna appeals first
  2. Request deadline: 180 days from final internal denial
  3. IRO assignment: Washington Insurance Commissioner assigns IRO within 3 business days
  4. Review timeline: 20 days for standard review, 72 hours for expedited
  5. Decision: Binding on Cigna if favorable

Washington Insurance Commissioner Support

Consumer Hotline: 1-800-562-6900 Website: insurance.wa.gov

The Commissioner's office provides:

  • Appeal guidance and template letters
  • IRO process assistance
  • Complaint investigation for unfair denials
  • Consumer advocacy services

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Insufficient PID diagnosis Submit complete immunology workup IgG/IgA/IgM levels, specific antibody responses, genetic testing if available
Lack of infection history Document recurrent infections Medical records showing frequency, severity, antibiotic courses
Step therapy not completed Show IVIG failure/intolerance Infusion records, adverse events, access issues
Exceeds quantity limits Justify weight-based dosing Body weight, BSA calculation, dosing rationale
"Not medically necessary" Provide clinical guidelines ESID/IUIS guidelines, immunology society recommendations

Clinician Corner: Medical Necessity Documentation

Essential elements for approval:

  • Diagnosis: Confirmed primary immunodeficiency with specific subtype
  • Laboratory evidence: Quantitative immunoglobulins, functional antibody studies
  • Clinical history: Recurrent bacterial infections, hospitalization frequency
  • Treatment rationale: Why subcutaneous route preferred over IVIG
  • Monitoring plan: IgG trough levels, infection tracking, quality of life measures

Key guidelines to reference:

Cost Considerations and Patient Assistance

Manufacturer support: Grifols offers patient assistance programs - check Grifols patient resources for eligibility.

Foundation grants: Consider immune deficiency foundation grants for copayment assistance.

State programs: Washington residents may qualify for additional assistance through Apple Health (Medicaid) coordination.

FAQ

How long does Cigna prior authorization take in Washington? Standard PA decisions: 72 hours after complete submission. Expedited requests: 24 hours for urgent medical situations.

What if Xembify is non-formulary on my Cigna plan? Your doctor can request a formulary exception, typically approved within 1-3 business days if clinical criteria are met showing medical necessity.

Can I request expedited appeal if denied? Yes, if your health could be seriously jeopardized by delay. Cigna must decide expedited appeals within 24 hours.

Does Washington state law help with Cigna denials? Yes, Washington provides strong external review rights through Independent Review Organizations, with decisions binding on insurers.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna staff. External reviews are conducted by independent medical experts assigned by the Washington Insurance Commissioner.

How do I transfer my prescription to Cigna specialty pharmacy? Call 1-800-351-3606. Cigna will coordinate with your prescriber and current pharmacy to transfer the prescription and arrange delivery.

When to Contact Counterforce Health

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. If your Xembify prior authorization is denied by Cigna, their platform can analyze the specific denial reasons and draft point-by-point rebuttals aligned with Cigna's own policies and Washington state requirements. The service is particularly valuable for complex immunodeficiency cases where clinical documentation and payer-specific appeal strategies make the difference between approval and continued denials.

Update Schedule

Insurance policies and forms change frequently. Check for updates:

  • Cigna forms: Quarterly via provider portal
  • Washington regulations: Monitor Insurance Commissioner updates
  • PA criteria: Review annually or after plan renewal
  • Specialty pharmacy contacts: Verify numbers before each use

Sources and Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance policies vary by plan and state. Always consult your healthcare provider and insurance documents for specific coverage details. For personalized assistance with Washington insurance appeals, contact the Washington State Office of the Insurance Commissioner at 1-800-562-6900.

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