By Counterforce Health Team in Aldurazyme (laronidase) —

Resources to Get Aldurazyme (laronidase) Approved with Cigna in Ohio: Forms, Appeals & Contact Guide

Answer Box: Getting Aldurazyme (laronidase) Covered by Cigna in Ohio

Fastest path to approval: Have your prescriber submit electronic prior authorization through CoverMyMeds or Cigna's provider portal, including genetic/biochemical MPS I confirmation, baseline assessments, and specialist attestation. If denied, request formulary exception within 72 hours, then pursue Ohio's external review process through the Department of Insurance (800-686-1526) within 180 days. Start today: Call Cigna member services at 1-800-244-6224 to verify your plan's specialty drug requirements and obtain your specific PA form.

Table of Contents

Start Here: Verify Your Plan Coverage

Before beginning the approval process, confirm your specific Cigna plan details and Aldurazyme coverage requirements.

Step 1: Log into myCigna.com or call the member services number on your ID card to verify:

  • Whether Aldurazyme requires prior authorization
  • Your plan's formulary tier for laronidase
  • Specialty pharmacy requirements (typically Accredo)
  • Any step therapy or quantity limit requirements

Step 2: Locate your plan's current drug formulary and coverage policies. Most Cigna plans require prior authorization for Aldurazyme due to its specialized use for mucopolysaccharidosis I (MPS I) and high cost (approximately $1,113 per 2.9 mg vial).

Note: Cigna typically manages specialty drugs through Express Scripts and Accredo. Verify your specific pharmacy benefit manager during this initial call.

Required Forms and Documentation

Prior Authorization Requirements

Your prescriber must submit a comprehensive PA request including:

Clinical Documentation:

  • Confirmed MPS I diagnosis with genetic or biochemical testing results
  • ICD-10 diagnosis codes (E76.01 for Hurler syndrome, E76.02 for Hurler-Scheie syndrome, E76.03 for Scheie syndrome)
  • Baseline disease severity assessments (pulmonary function, hepatosplenomegaly, joint mobility)
  • Treatment goals and monitoring plan for infusion reactions
  • Specialist attestation (typically geneticist, metabolic specialist, or pediatric specialist)

Administrative Information:

  • Patient demographics and Cigna ID number
  • Prescriber information and DEA number
  • Medication details: Aldurazyme (laronidase) 2.9 mg/5 mL vial for IV infusion
  • Dosing schedule: 0.58 mg/kg weekly IV infusion
  • Planned duration of therapy
  • Site of care and administration plan

Forms Access

Electronic Submission (Preferred):

  • CoverMyMeds portal - fastest processing
  • Cigna provider portal through myCigna
  • SureScripts electronic prescribing
  • Accredo's provider portal for specialty referrals

Paper Forms (if electronic unavailable):

Submission Portals and Methods

Electronic Prior Authorization (ePA)

Primary Options:

  1. CoverMyMeds: Most efficient option with real-time status updates
  2. Evicore by Evernorth: For Express Scripts coverage, select "Pharmacy Drug (Express Scripts Coverage)" option
  3. Cigna Provider Portal: Access through myCigna provider login
  4. Accredo Provider Portal: For specialty drug referrals and transfers

Submission Tips:

  • Complete all required fields to avoid processing delays
  • Upload supporting documentation (lab results, genetic testing, clinical notes)
  • Select "urgent" status if clinically appropriate
  • Save confirmation numbers and track submission status

Fax and Mail Backup

Cigna PA Fax: 855-840-1678 (verify on current form) Accredo Fax: 1-888-327-9791 for new prescriptions

Mailing Address for Appeals:

Cigna Appeals Unit
PO Box 188011
Chattanooga, TN 37422
Tip: Include a cover sheet with patient name, Cigna ID, prescriber contact information, and "URGENT - SPECIALTY DRUG PA REQUEST" if time-sensitive.

Specialty Pharmacy Setup: Accredo

Cigna partners with Accredo for most specialty medications including Aldurazyme. Once PA is approved, your prescription will typically be transferred to Accredo automatically.

Patient Enrollment Process

Step 1: Your prescriber sends the prescription to Accredo via:

  • Electronic prescribing (NCPDP 2623735)
  • Fax: 1-888-327-9791
  • Phone: 877-826-7657

Step 2: Accredo contacts you to:

  • Verify insurance benefits and copay assistance eligibility
  • Schedule delivery (including refrigerated shipping at no extra cost)
  • Provide medication counseling and infusion support resources
  • Coordinate with your infusion center if applicable

Step 3: Access ongoing support through:

  • Accredo patient portal for refill management
  • 24/7 pharmacist consultation at 877-826-7657
  • Text refill services (enrollment required)

Transfer from Retail Pharmacy

If you have an existing Aldurazyme prescription at a retail pharmacy:

  1. Log into myCigna and use the electronic transfer feature
  2. Call Accredo at 877-826-7657 to initiate transfer
  3. Provide your current pharmacy information and prescription details
  4. Accredo will contact your current pharmacy to complete the transfer

Support Lines and Contact Information

Cigna Member Services

  • Primary number: 1-800-244-6224 (24/7)
  • Website assistance: 1-800-853-2713 (24/7)
  • TTY/TDD: Dial 711 and follow prompts (24/7)

What to ask when calling:

  • "What are the specific PA requirements for Aldurazyme under my plan?"
  • "Is there a formulary exception process if the PA is denied?"
  • "What's the typical processing time for specialty drug PAs?"
  • "Do I need to use Accredo, or are other specialty pharmacies covered?"

Provider Support

  • Cigna Provider Services: Use number on provider ID card
  • Express Scripts PA Support: 800-753-2851
  • Accredo Provider Line: 877-826-7657

Case Management

For complex cases or repeated denials, request assignment to a Cigna case manager who can coordinate specialty drug approvals and provide ongoing support throughout treatment.

Appeals Process in Ohio

If your initial PA request is denied, Ohio law provides multiple levels of appeal.

Internal Appeals with Cigna

Timeline: Must be filed within 180 days of denial notice

Step 1 - Standard Internal Appeal:

  • Call Cigna member services or submit written appeal
  • Include denial notice, clinical justification, and supporting documentation
  • Decision timeline: 72 hours for standard requests

Step 2 - Expedited Appeal (if urgent):

  • Request expedited review if delay could seriously endanger health
  • Decision timeline: 24 hours

Formulary Exception Process

If Aldurazyme is non-formulary on your plan:

  1. Prescriber submits formulary exception request with clinical justification
  2. Must demonstrate medical necessity and failure/contraindication to formulary alternatives
  3. Decision timeline: 72 hours for standard, 24 hours for expedited

Ohio External Review

After exhausting internal appeals, you can request external review through the Ohio Department of Insurance.

Contact: Ohio Department of Insurance Consumer Services

  • Phone: 800-686-1526
  • Process: Request external review within 180 days of final internal denial
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: No charge to patient
  • Decision: Binding on Cigna if coverage is approved

Required Documentation:

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient diagnosis confirmation Submit genetic testing results and specialist evaluation Enzyme assay results, genetic panel, metabolic specialist report
Lack of baseline assessments Provide comprehensive disease severity documentation Pulmonary function tests, imaging studies, joint mobility assessments
Missing monitoring plan Detail infusion protocol and safety monitoring Infusion center protocols, emergency management plan, physician oversight
Quantity over limits Request quantity limit exception with clinical justification Weight-based dosing calculations, treatment guidelines citation
Non-formulary status Submit formulary exception with medical necessity letter Lack of therapeutic alternatives, FDA labeling, specialist guidelines

Medical Necessity Letter Checklist for Clinicians

When preparing appeals, include:

  • Problem: Confirmed MPS I diagnosis with specific subtype
  • Prior treatments: Document any previous therapies or explain why alternatives aren't appropriate
  • Clinical rationale: Reference FDA labeling and treatment guidelines
  • Dosing justification: Weight-based calculations (0.58 mg/kg weekly)
  • Monitoring plan: Infusion protocols and safety measures
  • Treatment goals: Specific clinical outcomes expected

Cost Assistance Options

Manufacturer Support Programs

Sanofi/BioMarin Patient Assistance: Contact manufacturer directly for copay assistance and patient support programs. Eligibility typically based on insurance status and income.

Foundation Grants

  • National Organization for Rare Disorders (NORD): Provides medication assistance grants
  • HealthWell Foundation: May offer copay assistance for eligible patients
  • Patient Advocate Foundation: Provides case management and financial assistance resources

State Programs

Ohio residents may be eligible for additional assistance through state-specific programs. Contact Ohio Department of Insurance Consumer Services at 800-686-1526 for guidance on available options.

When dealing with insurance coverage challenges, having the right support can make all the difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses that address specific payer requirements and deadlines.

FAQ

How long does Cigna prior authorization take for Aldurazyme in Ohio? Standard PA decisions are typically made within 72 hours of receiving complete documentation. Electronic submissions through CoverMyMeds or Cigna's provider portal often receive faster processing than fax submissions.

What if Aldurazyme is not on my Cigna formulary? Request a formulary exception through your prescriber. Cigna must respond within 72 hours for standard requests or 24 hours for expedited requests. Include clinical justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal if my PA is denied? Yes, if a delay in treatment could seriously endanger your health or ability to regain maximum function. Contact Cigna member services immediately to request expedited processing.

Does step therapy apply to Aldurazyme? Step therapy requirements vary by plan, but given that Aldurazyme is the only FDA-approved enzyme replacement therapy for MPS I, step therapy is less commonly applied. Verify your specific plan requirements.

What happens if Ohio external review denies coverage? External review decisions are binding on Cigna, but you retain rights to other remedies including regulatory complaints or legal action. Consult with a healthcare attorney if needed.

How do I transfer my prescription to Accredo? Log into myCigna and use the electronic transfer feature, or call Accredo at 877-826-7657. Accredo will coordinate with your current pharmacy to complete the transfer process.

Are there income requirements for manufacturer assistance programs? Requirements vary by program. Contact Sanofi/BioMarin patient services directly to determine eligibility for copay assistance and support programs.

Can I appeal if I live in Ohio but work in another state? Appeal rights depend on your specific plan type. Ohio's external review process applies to state-regulated plans, while self-funded employer plans follow federal ERISA rules. Contact Ohio Department of Insurance at 800-686-1526 for guidance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and requirements can change. Always verify current requirements with your specific Cigna plan and consult with your healthcare provider regarding treatment decisions. For personalized assistance with insurance appeals and coverage challenges, consider consulting with qualified professionals who specialize in healthcare coverage advocacy.

The Ohio Department of Insurance provides free consumer assistance and can help navigate the appeals process. Contact them at 800-686-1526 for support with coverage disputes and external review requests.

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