By Counterforce Health Team in Retevmo (selpercatinib) —

Renewing Retevmo (Selpercatinib) Approval with Cigna in Virginia: Complete Renewal Guide and Timeline

Answer Box: Retevmo (Selpercatinib) Renewal with Cigna in Virginia

Cigna requires prior authorization renewal for Retevmo (selpercatinib) every 12 months through Express Scripts/Accredo specialty pharmacy. Start your renewal 30-45 days before expiration with updated RET testing confirmation, disease status imaging, treatment response documentation, and an oncologist necessity letter citing NCCN guidelines. Submit via Cigna's provider portal or Accredo ePA. If denied, you have 180 days for internal appeal, then external review through Virginia's Bureau of Insurance within 120 days.

First step today: Contact your oncologist's office to schedule renewal packet preparation and verify your current approval expiration date.

Table of Contents

  1. Renewal Triggers: When to Start Early
  2. Evidence Update Requirements
  3. Renewal Packet Essentials
  4. Timeline and Submission Process
  5. If Coverage Lapses
  6. Annual Plan Changes to Monitor
  7. Personal Tracking Template
  8. Appeals Process in Virginia
  9. FAQ

Renewal Triggers: When to Start Early

Standard Renewal Timeline

Most Cigna prior authorizations for Retevmo (selpercatinib) are approved for 12 months. However, some approvals may be shorter based on:

  • Disease progression concerns
  • Significant side effects requiring monitoring
  • Plan-specific policies
Tip: Check your approval letter or EOB for the exact expiration date. Don't rely on pharmacy refill dates alone.

Start Early If You Have:

  • Complex medical history requiring extensive documentation
  • Previous denials that needed appeals
  • Upcoming travel or medical procedures
  • Recent dose changes due to side effects
  • New insurance effective dates (January 1st renewals)

Recommended start time: 30-45 days before expiration for standard cases, 60+ days for complex situations.

Evidence Update Requirements

Core Documentation for Renewal

RET Alteration Confirmation Your renewal must include current RET testing results from an FDA-approved test such as:

  • FoundationOne CDx
  • Guardant360 CDx
  • MSK-IMPACT
  • Other validated NGS panels
Note: If your original testing was incomplete or unclear, Cigna may request repeat testing even for renewals.

Disease Status Assessment Include recent imaging showing:

  • Current disease extent (stable, progressing, or responding)
  • RECIST response criteria documentation
  • Comparison to baseline scans
  • New lesions or progression sites

Treatment Response Documentation Your oncologist should document:

  • Clinical benefit from Retevmo (symptom improvement, performance status)
  • Tolerability and side effect management
  • Adherence to therapy
  • Quality of life improvements

Required Laboratory Monitoring

Based on FDA labeling requirements, your renewal packet should include:

Test Frequency Why It Matters
ALT/AST Every 2 weeks × 3 months, then monthly Hepatotoxicity monitoring
Electrolytes (K, Mg, Ca) Monthly QT prolongation prevention
ECG/QTc Monthly × 6 months, then as needed Cardiac safety
Blood pressure Weekly initially, then monthly Hypertension management
TSH Baseline and periodically Thyroid function

Renewal Packet Essentials

Medical Necessity Letter Structure

Your oncologist should address these key points:

1. Current Clinical Status

  • Diagnosis with ICD-10 codes
  • Disease stage and extent
  • Performance status (ECOG)

2. Treatment History

  • Prior therapies tried and failed
  • Reasons for discontinuation (progression, intolerance)
  • Duration of current Retevmo therapy

3. Evidence of Benefit

  • Imaging response or stability
  • Symptom improvement
  • Quality of life measures

4. Guideline Support

  • NCCN Compendium recommendations
  • FDA-approved indications
  • Peer-reviewed literature support

5. Safety Monitoring

  • Adverse event management
  • Laboratory monitoring compliance
  • Dose modifications if needed

Required Supporting Documents

Clinical Records

  • Recent progress notes (last 3-6 months)
  • Imaging reports with measurements
  • Laboratory results showing safety monitoring
  • Pathology reports confirming RET alteration

Administrative Documents

  • Current insurance card
  • Previous approval letter
  • Pharmacy records showing adherence
  • Prior denial letters (if applicable)

Timeline and Submission Process

Submission Methods

Cigna Provider Portal (Preferred)

  • Log in to CignaForHCP.com
  • Submit electronically for faster processing
  • Track status in real-time

Express Scripts/Accredo ePA

  • Access via MyAccredoPatients.com
  • Specialty pharmacy integration
  • Direct communication with dispensing pharmacy

Processing Timeline

Review Type Standard Timeline Expedited Timeline
Initial Review 72 hours 24 hours
Additional Information 14 days 72 hours
Peer-to-Peer Review 72 hours after request 24 hours
Important: Expedited reviews require physician attestation of urgent medical need.

If Coverage Lapses

Immediate Steps

1. Contact Cigna Member Services Call the number on your insurance card to:

  • Verify renewal status
  • Request expedited processing
  • Ask about retroactive coverage

2. Pharmacy Bridge Options

  • Manufacturer assistance: Lilly Cares Foundation may provide temporary supply
  • Copay assistance: Retevmo Savings Card (verify eligibility)
  • Hospital/clinic samples: Ask your oncologist about available samples

3. Appeal Process If renewal is denied, initiate internal appeal immediately:

  • Submit within 180 days of denial
  • Request expedited review for cancer treatment
  • Gather additional supporting evidence

Treatment Continuity Considerations

Clinical Monitoring During Gaps

  • Continue safety lab monitoring
  • Watch for disease progression symptoms
  • Maintain communication with oncology team

Alternative RET Inhibitor Options If Retevmo renewal fails, discuss with your oncologist:

  • Gavreto (pralsetinib): Alternative RET inhibitor
  • Clinical trials: Research ongoing studies
  • Compassionate use: Direct manufacturer programs

Annual Plan Changes to Monitor

Formulary Updates

Cigna typically updates formularies annually on January 1st. Recent changes have affected specialty oncology drugs:

What to Verify Each Year:

  • Formulary tier placement (preferred vs. non-preferred)
  • Prior authorization requirements
  • Quantity limits
  • Site of care restrictions
  • Step therapy requirements

Plan Design Changes

Potential Impact Areas:

  • Copay/coinsurance amounts
  • Specialty pharmacy requirements
  • Coverage determination processes
  • Appeal procedures
Action Item: Review your Annual Notice of Changes (typically mailed in October) for benefit modifications.

Personal Tracking Template

Renewal Checklist

45 Days Before Expiration:

  • Schedule oncology appointment
  • Order updated imaging
  • Request current lab results
  • Gather prior treatment records

30 Days Before:

  • Obtain medical necessity letter
  • Compile complete renewal packet
  • Submit prior authorization
  • Confirm receipt with Cigna

15 Days Before:

  • Follow up on approval status
  • Request expedited review if needed
  • Prepare appeal documents if denied

At Expiration:

  • Verify approval received
  • Update pharmacy records
  • Schedule next renewal reminder

Appeals Process in Virginia

Internal Appeals with Cigna

Level 1: Standard Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for decision (72 hours expedited)
  • Submit to: Cigna appeals department via provider portal

Level 2: Second Internal Review

  • Automatic: If Level 1 denied
  • Timeline: 30 days for decision
  • Includes: Independent medical review

External Review in Virginia

If internal appeals fail, Virginia's Bureau of Insurance provides external review:

Eligibility Requirements:

  • Completed all internal appeals
  • Denial based on medical necessity
  • Virginia-issued insurance plan

Process Steps:

  1. File within 120 days of final internal denial
  2. Use Form 216-A (External Review Request)
  3. Submit to: Virginia Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218
  4. Timeline: 45 days for standard review, 72 hours for expedited

Required Documents:

  • Final denial letter from Cigna
  • Medical records supporting necessity
  • Physician attestation for expedited review
  • Completed Form 216-A
Virginia Advantage: The state allows expedited external review for cancer treatments without exhausting all internal appeals in urgent cases.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeal processes for specialty medications like Retevmo.

FAQ

How long does Cigna take to approve Retevmo renewals? Standard reviews take 72 hours, while expedited reviews for urgent medical need take 24 hours. Complex cases requiring additional documentation may take up to 14 days.

What if my RET testing was done years ago? Cigna typically accepts historical RET testing for renewals if the original report clearly documents the specific alteration. However, they may request repeat testing if results are unclear or incomplete.

Can I appeal if Retevmo becomes non-formulary? Yes, you can request a formulary exception through Cigna's standard appeal process. Include documentation showing medical necessity and lack of suitable formulary alternatives.

Does Virginia have special protections for cancer patients? Virginia allows expedited external review for cancer treatments and doesn't require exhausting all internal appeals for urgent cases. The state also provides free external review services through the Bureau of Insurance.

What happens if I switch Cigna plans mid-year? Your prior authorization may need to be resubmitted under the new plan's requirements. Contact Cigna member services immediately to understand any changes in coverage criteria.

How much does Retevmo cost without insurance? Cash prices range from $23,000-$26,000 per 30-day supply. Manufacturer assistance through Lilly Cares Foundation may be available for eligible patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For assistance with complex appeals, consider consulting with organizations like Counterforce Health that specialize in insurance coverage advocacy.

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