By Counterforce Health Team in Elzonris (tagraxofusp-erzs) —

Lowering Out-of-Pocket for Elzonris (Tagraxofusp-erzs) with Cigna in Ohio: Complete Copay, Tiering & Financial Assistance Guide

Answer Box: Getting Elzonris Covered by Cigna in Ohio

Elzonris (tagraxofusp-erzs) requires prior authorization from Cigna and is placed in Tier 4 (specialty tier) with high out-of-pocket costs. To minimize expenses: (1) Apply for Stemline's copay card (up to $25,000/year coverage) and patient assistance program (free drug if uninsured, income ≤500% FPL), (2) request NORD's BPDCN-specific copay assistance for deductibles/specialist visits, and (3) if denied coverage, appeal within 180 days using Ohio's external review process through the Department of Insurance. Start today: Call Stemline ARC at 833-478-3654 to enroll in financial assistance programs while your doctor submits the prior authorization.

Table of Contents

  1. What Drives Elzonris Costs with Cigna
  2. Benefit Investigation: What to Ask
  3. Financial Assistance Options
  4. Requesting Tier Exceptions
  5. Specialty Pharmacy Coordination
  6. Appeals on Cost Grounds
  7. Annual Renewal Planning
  8. Conversation Scripts
  9. FAQ

What Drives Elzonris Costs with Cigna

Understanding Cigna's benefit structure helps you navigate the financial landscape for Elzonris, which carries a list price of approximately $38,579 per 1,000 mcg vial.

Tier Placement Impact

Cigna places Elzonris in Tier 4 (specialty tier) on most formularies, meaning:

  • Highest coinsurance: Often 25-40% of drug cost
  • Specialty pharmacy requirement: Must fill through Accredo
  • 30-day supply limits: No 90-day fills available
  • Prior authorization: Required before any coverage
Note: Your specific plan may vary. Always verify your formulary tier by searching "Elzonris" or "tagraxofusp" on Cigna's drug list tool.

Key Cost Drivers

Factor Impact Your Action
Deductible Pay full cost until met (often $3,000-8,000) Apply for copay assistance first
Coinsurance 25-40% of $38,579 = $9,645-15,432 per vial Request tier exception to lower tier
Out-of-pocket maximum $8,700-18,200 annually (ACA plans) Track spending; hit max early in year
Prior authorization Denial = 100% out-of-pocket Submit complete clinical documentation

Benefit Investigation: What to Ask

Before starting Elzonris, gather specific benefit details to plan your financial strategy.

Essential Questions for Cigna

Call the number on your insurance card and ask:

  1. "What tier is Elzonris (tagraxofusp-erzs) on my specific formulary?"
  2. "What's my specialty drug coinsurance percentage?"
  3. "Do I have a separate specialty drug deductible?"
  4. "What's my annual out-of-pocket maximum for specialty drugs?"
  5. "Which specialty pharmacy must I use - is it Accredo?"

Information to Record

Create a file with:

  • Policy number and group number
  • Deductible remaining this year
  • Specialty drug benefit details
  • Prior authorization requirements
  • Appeals process contact information
Tip: Request this information in writing via your Cigna member portal for future reference.

Financial Assistance Options

Multiple programs can significantly reduce your Elzonris costs, often stacking together for maximum savings.

Manufacturer Programs (Stemline Therapeutics)

Stemline ARC Copay Card

  • Coverage: Up to $25,000 per calendar year
  • Eligibility: Commercial insurance (not Medicare/Medicaid)
  • Enrollment: ELZONRIScopay.com or call 833-478-3654
  • Result: Many patients pay $0 per month

Patient Assistance Program (PAP)

  • Coverage: Free Elzonris for eligible patients
  • Eligibility: Uninsured or functionally uninsured, household income ≤500% Federal Poverty Level
  • Application: Fax completed form to 1-833-329-7836
  • Timeline: Review within 2-3 business days

Foundation Grants

NORD BPDCN-Specific Programs NORD offers targeted assistance for BPDCN patients:

  • Copay assistance: Insurance deductibles, specialist visits, ER copays
  • Travel/lodging: Reimbursement for treatment center visits
  • Emergency relief: Utilities, car repairs due to lost wages from treatment

Contact: 1-800-999-6673 (Monday-Thursday, 8:30am-7pm ET)

Other Foundation Options

  • PAN Foundation: Check for BPDCN or blood cancer funds at panapply.org
  • Leukemia & Lymphoma Society: General blood cancer patient aid via LLS.org
  • HealthWell Foundation: Search for rare disease copay assistance at HealthWellFoundation.org

Stacking Strategies

Most effective approach:

  1. Primary: Stemline copay card (covers up to $25,000)
  2. Secondary: NORD grants for non-drug costs (deductibles, travel)
  3. Tertiary: Other foundations for remaining gaps

Counterforce Health specializes in helping patients navigate these complex assistance programs while simultaneously managing the prior authorization and appeals process, ensuring no financial opportunity is missed.

Requesting Tier Exceptions

If Elzonris costs remain prohibitive even with assistance, request a formulary exception to move it to a lower tier.

When to Request

  • Monthly costs exceed $500-1,000 despite assistance
  • Lower-tier alternatives are contraindicated
  • You've failed step therapy requirements on other drugs

Required Documentation

Medical Necessity Letter must include:

  • BPDCN diagnosis with ICD-10 code C86.4
  • CD123-positive pathology results
  • Prior treatment failures or contraindications
  • Clinical rationale citing FDA approval for BPDCN
  • Monitoring plan for capillary leak syndrome

Submission Process

  1. Provider submits via Cigna provider portal or fax
  2. Include tier exception request form (obtain from Cigna)
  3. Timeline: 72 hours for urgent, 14 days standard
  4. Appeal if denied: Follow standard appeal process
From our advocates: We've seen tier exceptions succeed most often when the medical necessity letter specifically addresses why alternatives at lower tiers are inappropriate, rather than simply stating Elzonris is preferred. Include specific contraindications or prior failures with documentation.

Specialty Pharmacy Coordination

Cigna typically requires Elzonris fills through Accredo Specialty Pharmacy, but coordination can impact your costs.

Accredo Benefits

  • Copay card processing: Automatically applies manufacturer savings
  • Clinical support: Nurses help with side effect management
  • Prior authorization: Handles PA submissions and appeals
  • Delivery coordination: Ships to clinic for infusion

Cost Optimization Tips

Timing Strategies:

  • January fills: Hit deductible early when assistance programs reset
  • End-of-year planning: Maximize out-of-pocket limits before benefits reset

Coordination with Assistance:

  • Provide copay card information during first Accredo call
  • Confirm foundation grants are applied before each shipment
  • Request detailed billing statements for tax/assistance documentation

Alternative Pharmacy Options

Some Cigna plans allow:

  • Buy-and-bill: Clinic purchases, bills insurance directly
  • Other specialty pharmacies: If Accredo creates access issues

Verify first: Call Cigna to confirm approved specialty pharmacies for your plan.

Appeals on Cost Grounds

When coverage is approved but costs remain unaffordable, specific appeal strategies can help.

Grounds for Cost-Based Appeals

  • Tier placement: Request lower tier based on medical necessity
  • Quantity limits: Appeal monthly supply restrictions
  • Site of care: Challenge requirements for inpatient-only administration
  • Step therapy: Expedite based on diagnosis severity

Ohio-Specific Appeal Process

Internal Appeals (Required first):

  1. Timeline: 180 days from denial or adverse benefit determination
  2. Submission: Via myCigna.com or mail to address on denial letter
  3. Documentation: Include financial hardship letter, clinical necessity, alternative cost comparisons

External Review (After internal appeals):

Required Documentation

  • Complete denial letters and appeals correspondence
  • Medical necessity documentation
  • Financial hardship statement
  • Evidence of assistance program applications
  • Comparative cost analysis of alternatives

Annual Renewal Planning

Plan ahead to minimize cost disruptions when benefits reset.

December Preparation

Benefits Review:

  • Confirm Elzonris remains covered on next year's formulary
  • Check for tier changes or new restrictions
  • Review deductible and out-of-pocket maximum changes

Assistance Program Renewals:

  • Stemline copay card: Automatically resets January 1st
  • Foundation grants: Reapply in December for next year funding
  • Income documentation: Update for assistance programs

January Actions

  1. Refill immediately: Use remaining current-year benefits
  2. Resubmit PA: If required annually by your plan
  3. Activate assistance: Ensure all programs are active for new benefit year
  4. Track spending: Monitor progress toward new deductible/out-of-pocket max
Tip: Counterforce Health helps coordinate these annual transitions, ensuring continuous coverage while maximizing assistance program benefits across benefit year boundaries.

Conversation Scripts

Calling Cigna Member Services

"Hi, I'm calling about coverage for Elzonris, spelled E-L-Z-O-N-R-I-S, generic name tagraxofusp-erzs. I need to understand my specific benefits for this specialty medication. Can you tell me what tier it's on for my plan, what my coinsurance percentage is, and whether I need to use Accredo pharmacy?"

Provider Office Financial Counselor

"I'm starting Elzonris and want to minimize out-of-pocket costs. Can you help me apply for the manufacturer copay card and check if there are foundation grants available? I'd also like to understand if a tier exception might be appropriate for my situation."

Accredo Specialty Pharmacy

"I'm filling Elzonris and have enrolled in the Stemline copay card program. Please confirm this is applied to my account and let me know what my expected out-of-pocket cost will be for each shipment. I also have foundation grants that may apply."

FAQ

How long does Cigna prior authorization take for Elzonris in Ohio? Standard PA decisions take 5-7 business days for complete submissions. Expedited reviews (for urgent cases) are completed within 72 hours. Incomplete submissions may take longer pending additional documentation.

What if Elzonris is non-formulary on my Cigna plan? You can request a formulary exception through your doctor. Include medical necessity documentation showing why covered alternatives are inappropriate. If denied, appeal through Cigna's internal process, then Ohio's external review.

Can I request an expedited appeal if I can't afford my copay? Expedited appeals are typically reserved for urgent medical situations, not financial hardship alone. However, if delayed treatment would cause serious health consequences, document this in your expedited appeal request.

Does the Stemline copay card work with all Cigna plans? The copay card works with most commercial Cigna plans but not Medicare or Medicaid. Some employer plans may restrict copay card use - verify with both Cigna and Stemline before relying on this assistance.

How much can foundation grants reduce my Elzonris costs? NORD's BPDCN programs can cover insurance deductibles, specialist copays, and travel costs. Combined with the Stemline copay card, many patients reduce monthly costs to under $100. Exact amounts depend on your specific insurance and financial situation.

What happens if I hit my out-of-pocket maximum? Once you reach your annual out-of-pocket maximum (typically $8,700-18,200), Cigna covers 100% of Elzonris costs for the remainder of the benefit year. This makes early-year treatment planning crucial.

Can I switch specialty pharmacies if Accredo creates problems? Some Cigna plans allow alternative specialty pharmacies, but this varies by plan. Contact Cigna member services to confirm approved options. Switching may require new prior authorization.

How do I track all my assistance programs and deadlines? Create a calendar with renewal dates for copay cards (January 1st), foundation grant applications (typically December), and PA renewals. Keep a file with all confirmation numbers and contact information.

Sources & Further Reading

This guide provides educational information about insurance coverage and financial assistance options. It is not medical advice. Always consult with your healthcare provider about treatment decisions and verify current coverage details with your insurance plan. For personalized assistance with prior authorizations and appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

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