By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

Resources to Get Arikayce (Amikacin Liposome Inhalation) Approved with Cigna in Pennsylvania: Complete Forms, Portals & Contact Guide

Answer Box: Getting Arikayce Covered by Cigna in Pennsylvania

Fastest path to approval: Your pulmonologist must submit a prior authorization request through Cigna's provider portal or call 1-800-882-4462, documenting refractory MAC lung disease with ≥6 months of failed multi-drug therapy and positive cultures. First step today: Contact your specialist's office to request they initiate the PA process using Cigna's Arikayce policy criteria. If denied, Pennsylvania's new external review program overturns about 50% of appeals within 45 days.

Table of Contents

  1. Start Here: Verify Your Plan and Find the Right Forms
  2. Required Forms for Cigna Prior Authorization
  3. Submission Portals and Electronic Systems
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Setup with Accredo
  6. Key Phone Numbers and Support Lines
  7. Pennsylvania External Review Process
  8. Update Schedule and Resource Maintenance

Start Here: Verify Your Plan and Find the Right Forms

Before starting your Arikayce prior authorization, confirm your exact Cigna plan type by checking your member ID card or logging into myCigna.com. The forms and submission process vary slightly between:

  • Commercial/Employer Plans (most common)
  • Individual/Marketplace Plans
  • Cigna Medicare Advantage or Part D
  • Cigna+Oscar Plans

All Cigna plans use the same clinical criteria for Arikayce: refractory MAC lung disease in adults with positive cultures after ≥6 months of combination therapy, prescribed by a specialist.

Tip: Most Cigna specialty medications must be filled through Accredo Specialty Pharmacy for coverage. Verify this requirement in your plan documents.

Required Forms for Cigna Prior Authorization

Core Prior Authorization Form

Cigna uses a national Arikayce prior authorization policy rather than state-specific forms. Your provider needs:

  • Electronic Prior Authorization (ePA) through Surescripts, CoverMyMeds, or Express Scripts provider portal (preferred method)
  • Generic drug PA form if ePA unavailable - contact Cigna Provider Services at 1-800-882-4462

Formulary Exception Forms (if Arikayce is non-formulary)

For Pennsylvania residents with commercial plans:

For Medicare plans:

Supporting Documentation Checklist

Your pulmonologist's office should prepare:

  • Medical necessity letter addressing Cigna's specific criteria
  • MAC diagnosis confirmation (culture results, imaging)
  • Documentation of ≥6 months failed combination therapy
  • Amikacin susceptibility testing results
  • Current positive MAC cultures
  • Specialist credentials verification

Submission Portals and Electronic Systems

Provider Electronic Submission

Primary Method: EviCore by Evernorth for Express Scripts-managed pharmacy benefits

Alternative Methods:

  • CoverMyMeds portal (requires provider account)
  • Surescripts ePA network
  • Express Scripts provider portal

Member/Patient Access

myCigna Portal: myCigna.com or mobile app

  • View prior authorization status
  • Track Accredo shipments once approved
  • Access plan formulary and coverage details
Note: Pennsylvania members under age 13 cannot register independently at myCigna.com per Cigna's policy.

Fax Numbers and Mailing Addresses

Prior Authorization Submission

Phone for PA-specific fax numbers: 1-800-882-4462 (provider services)

  • Fax numbers vary by plan type and region
  • Always include cover sheet with member ID, provider NPI, and "URGENT" if expedited review needed

Appeals and Grievances

Standard mailing address for many Cigna plans:

Cigna Healthcare
PO Box 5200
Scranton, PA 18505

For appeals: Use the specific address provided in your denial letter, as this varies by plan administrator.

Specialty Pharmacy Setup with Accredo

Enrollment Process

  1. Provider sends prescription directly to Accredo Specialty Pharmacy after PA approval
  2. Accredo contacts patient within 2-3 business days to verify:
    • Shipping address and preferred delivery time
    • Insurance information and copay details
    • Nebulizer equipment needs
  3. Patient setup includes:
    • Automatic refill reminders (opt-in)
    • Text message notifications
    • Clinical support from Accredo pharmacists

Transfer from Another Pharmacy

  • Cancel existing refills at current pharmacy
  • Request new prescription sent directly to Accredo
  • Don't rely on transfer requests - new prescription ensures proper billing

Counterforce Health can help coordinate this transition by working with your clinical team to ensure all documentation supports the specialty pharmacy requirement and prior authorization criteria are met.

Key Phone Numbers and Support Lines

Member Services

  • General Cigna Member Services: 1-800-244-6224 (24/7)
  • Medicare Part D Members: 1-800-222-6700 (8am-8pm, 7 days/week)
  • TTY/TDD: Dial 711 for any Cigna number

Provider Services

  • Provider Services Line: 1-800-882-4462
  • Precertification/Prior Auth: Use provider services number above
  • Claims and Payment: Same number, select appropriate menu option

Specialty Pharmacy Support

  • Accredo Member Services: Number provided after enrollment
  • Cigna Specialty Pharmacy: Access through main member services line

What to Ask When You Call

For Members: "I need help with a prior authorization for Arikayce for refractory MAC lung disease. Can you connect me to pharmacy benefits and confirm if an expedited review is available?"

For Providers: "I'm submitting a prior authorization for Arikayce under your inhaled antibiotics policy. What's the current fax number and can you confirm the clinical criteria requirements?"

Pennsylvania External Review Process

Pennsylvania's Independent External Review Program

Pennsylvania launched its own external review system in January 2024, with impressive results: approximately 50% of appealed denials are overturned, according to the Pennsylvania Insurance Department.

Timeline and Process

  1. Complete Cigna's internal appeals first (required except for urgent cases)
  2. Request external review within 4 months of final denial letter
  3. Submit through PID portal or mail forms to Pennsylvania Insurance Department
  4. Decision within 45 days (standard) or 72 hours (expedited)

How to File

Online: Pennsylvania Insurance Department External Review Portal

Phone: 1-877-881-6388 (PID Consumer Services)

Required Documents:

  • Final denial letter from Cigna
  • All internal appeal correspondence
  • Medical records supporting medical necessity
  • Completed external review application
From our advocates: We've seen cases where Pennsylvania's external review process succeeded after internal appeals failed, particularly when the clinical documentation clearly showed Arikayce met refractory MAC criteria but the initial reviewer missed key details about prior therapy failures.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Provider submits before prescribing Cigna PA Policy
Age Requirement Must be >18 years Patient's date of birth Same policy document
Refractory Disease ≥6 months failed combination therapy Treatment history documentation Same policy document
Specialist Prescriber Pulmonologist or ID specialist required Provider credentials Same policy document
Accredo Pharmacy Most plans require specialty pharmacy Plan documents in myCigna Cigna Specialty Pharmacy Guide
Appeals Deadline 180 days for internal, 4 months for external Denial letter date PA External Review

Update Schedule and Resource Maintenance

When to Check for Updates

  • Quarterly: Cigna updates formularies and prior authorization criteria
  • Annually: Medicare plans change significantly each October-December
  • After denials: Policies may have been updated since your last submission

Key Resources to Monitor

  1. Cigna PA policies: Check coverage position criteria page - last updated 10/23/2024
  2. Pennsylvania external review: Monitor PID website for process changes
  3. Formulary status: Check your plan's current drug list in myCigna

Frequently Asked Questions

How long does Cigna prior authorization take in Pennsylvania? Standard requests: 72 hours for non-urgent, 24 hours for expedited. If Cigna doesn't respond within these timeframes after receiving complete information, the request is deemed approved.

What if Arikayce is non-formulary on my plan? Submit a formulary exception request using the exception process forms with strong medical necessity documentation.

Can I request an expedited appeal in Pennsylvania? Yes, if delay could seriously jeopardize your health. Both Cigna and Pennsylvania's external review offer expedited timelines for urgent cases.

Does step therapy apply if I failed treatments outside Pennsylvania? Yes, document all prior therapies regardless of where they occurred. Cigna's policy requires ≥6 months of combination therapy, not location-specific treatment.

What happens if Pennsylvania external review overturns the denial? Cigna must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal process.

When You Need Additional Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and craft appeals that address payers' specific criteria and procedural requirements.

For Arikayce cases, we help ensure your appeal includes the right FDA labeling citations, peer-reviewed studies on refractory MAC treatment, and specialty guidelines that support medical necessity - all aligned to Cigna's own coverage rules and Pennsylvania's appeal procedures.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for coverage determinations. For assistance with insurance appeals and coverage issues in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

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