By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

The Complete Checklist to Get Eylea or Lucentis Covered by Cigna in New York: Forms, Appeals, and Timeline Guide

Answer Box: Your Path to Coverage

Eligibility: Cigna typically covers Eylea and Lucentis for wet AMD, diabetic macular edema, and retinal vein occlusion with prior authorization. Most plans require step therapy with bevacizumab first unless contraindicated.

Fastest approval path: Have your retina specialist submit electronic prior authorization through Cigna's provider portal with complete documentation: diagnosis with ICD-10 code, visual acuity measurements, OCT imaging showing active disease, and detailed prior treatment history.

Start today: Call the number on your Cigna ID card to verify if your specific plan requires prior authorization and whether Express Scripts/Accredo handles specialty pharmacy routing.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation
  5. Your Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Prevention Tips
  10. Appeals Process in New York
  11. Quick Reference Checklist

Who Should Use This Guide

This guide is designed for New York residents with Cigna coverage who need Eylea (aflibercept) or Lucentis (ranibizumab) for:

  • Wet age-related macular degeneration (nAMD)
  • Diabetic macular edema
  • Diabetic retinopathy
  • Retinal vein occlusion with macular edema

Expected outcome: With complete documentation, most prior authorizations are approved within 3-5 business days. If denied initially, proper appeals have strong success rates, especially when clinical guidelines and imaging clearly support medical necessity.

Member & Plan Basics

Verify Your Coverage Status

Before starting the prior authorization process:

  1. Confirm active Cigna coverage by logging into your myCigna portal or calling the member services number on your ID card
  2. Identify your plan type: Commercial, Medicare Advantage, or Medicaid managed care affects which forms and processes apply
  3. Check deductible status: High-deductible plans may require meeting your deductible before coverage begins
  4. Verify specialty pharmacy requirements: Many Cigna plans mandate using Accredo for specialty medications

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for both Eylea and Lucentis Cigna formulary documents
Formulary Tier Typically specialty tier with higher copays Check myCigna portal or call member services
Step Therapy Often requires bevacizumab trial first Cigna step therapy policies
Quantity Limits Usually limited to monthly injections initially Varies by plan; check with provider services

Clinical Criteria Requirements

FDA-Approved Indications

Cigna covers Eylea and Lucentis for these labeled uses:

  • Neovascular (wet) age-related macular degeneration
  • Diabetic macular edema
  • Macular edema following retinal vein occlusion
  • Diabetic retinopathy (specific products and strengths vary)

Step Therapy Requirements

Most Cigna plans require documentation of:

  1. Bevacizumab trial with adequate dose and duration (typically 3+ injections over 3-6 months)
  2. Inadequate response documented by visual acuity and OCT measurements
  3. Or contraindication to bevacizumab (allergy, prior adverse reaction, specific clinical factors)

Dosing and Duration Approval

  • Loading phase: Monthly injections typically approved for 3-6 months
  • Maintenance phase: Extended intervals (every 8-16 weeks) based on treatment response
  • Monitoring requirements: Regular visual acuity and OCT documentation required for renewals

Coding and Documentation

Essential ICD-10 Codes

Wet AMD:

  • H35.3211-H35.3213: Exudative AMD with active choroidal neovascularization (specify right, left, bilateral)

Diabetic Macular Edema:

  • E11.3211-E11.3213: Type 2 diabetes with mild nonproliferative retinopathy with macular edema
  • E11.3311-E11.3313: Type 2 diabetes with moderate nonproliferative retinopathy with macular edema

Retinal Vein Occlusion:

  • H34.8110-H34.8113: Central retinal vein occlusion (specify eye)
  • H35.81: Retinal edema (when present with RVO)

HCPCS J-Codes and Units

Drug HCPCS Code Units per Injection Billing Notes
Eylea 2mg J0178 2 units Per 1mg, so 2 units for standard 2mg dose
Lucentis 0.5mg J2778 5 units Per 0.1mg, so 5 units for 0.5mg dose
Lucentis 0.3mg J2778 3 units Per 0.1mg, so 3 units for 0.3mg dose

Your Documentation Packet

Medical Necessity Letter Components

Your ophthalmologist should include:

  1. Patient identifiers: Name, DOB, Cigna member ID, affected eye(s)
  2. Specific diagnosis with ICD-10 code and date of diagnosis
  3. Baseline clinical status:
    • Best-corrected visual acuity in each eye with dates
    • OCT findings: central macular thickness, presence of intraretinal/subretinal fluid
  4. Treatment history:
    • All prior anti-VEGF therapies with dates, number of injections, and response
    • Documentation of bevacizumab trial and failure (if step therapy applies)
  5. Clinical rationale for requested drug with supporting literature
  6. Treatment plan: Proposed dosing schedule and monitoring plan
Clinician Corner: Strong medical necessity letters directly address Cigna's specific criteria found in their anti-VEGF policy documents. Include quantitative OCT measurements and cite relevant clinical guidelines like those from the American Academy of Ophthalmology.

Required Attachments

  • Recent OCT report or printouts showing active disease
  • Visual acuity measurements (baseline and current)
  • Office visit notes documenting examination findings
  • Prior authorization forms from previous anti-VEGF treatments (if applicable)
  • Imaging studies (fluorescein angiography if performed)

Submission Process

  1. Access Cigna provider portal or use common e-PA platforms like CoverMyMeds
  2. Complete anti-VEGF prior authorization form with all required clinical data
  3. Upload supporting documentation including medical necessity letter and imaging
  4. Mark as urgent if there's risk of imminent vision loss

Alternative Submission Methods

If electronic submission isn't available:

  • Fax: Use the provider services fax number found on current Cigna PA forms
  • Mail: Send to the address specified on the prior authorization form
  • Phone: Call for expedited review in urgent cases
Tip: Electronic submissions typically process 1-2 days faster than fax submissions and reduce the risk of missing documentation.

Specialty Pharmacy Routing

Accredo Coordination

Many Cigna plans require specialty drugs to be dispensed through Accredo:

  1. Verify requirement by checking your plan benefits or calling member services
  2. Provider enrollment: Your clinic may need to register with Accredo's prescriber portal
  3. Shipment coordination: Align drug delivery with injection appointments
  4. Buy-and-bill alternative: Some plans allow office purchase and billing

For practices new to Accredo, register at their prescriber portal and allow extra time for initial setup.

After Submission: What to Expect

Timeline Expectations

  • Standard review: 3-5 business days for complete submissions
  • Expedited review: 24-72 hours when marked urgent with proper documentation
  • Incomplete submissions: May take 7-14 days if additional information is requested

Status Tracking

  1. Record confirmation numbers from electronic or phone submissions
  2. Check status through Cigna provider portal or by calling provider services
  3. Document all communications including reference numbers and representative names

What to Record

  • Submission date and method
  • Confirmation or reference numbers
  • Any requests for additional information
  • Approval or denial notification dates
  • Appeal deadlines if denied

Common Denial Prevention Tips

Five Pitfalls to Avoid

  1. Incomplete step therapy documentation: Always include detailed bevacizumab trial history with specific dates, doses, and response measurements
  2. Missing OCT evidence: Ensure current OCT clearly shows active disease with quantifiable fluid or thickening
  3. Vague medical necessity: Generic letters often fail—be specific about why this patient needs this particular drug
  4. Wrong diagnosis codes: Use the most specific ICD-10 code that matches your documentation
  5. Inadequate visual acuity documentation: Include baseline and current measurements with standardized testing methods

Success Strategies

  • Use Cigna-specific forms: Download current versions from their provider portal
  • Address coverage criteria directly: Reference specific policy requirements in your letter
  • Quantify clinical findings: Include specific measurements, not just qualitative descriptions
  • Cite supporting literature: Include relevant clinical guidelines and studies
  • Follow up promptly: Don't wait—check status within 3-5 business days

Appeals Process in New York

Internal Appeals with Cigna

If your initial prior authorization is denied:

  1. Review the denial letter carefully to understand the specific reason
  2. File internal appeal within 180 days of the denial date
  3. Submit additional documentation addressing the denial reason
  4. Request expedited review if urgent (decision within 72 hours)

New York External Appeals

New York residents have strong appeal rights through the Department of Financial Services:

When to use: After receiving a final adverse determination from Cigna's internal appeal process, or if Cigna waives internal appeals

Timeline: Must file within 4 months of Cigna's final denial

Process:

  1. Download the NY DFS External Appeal Application
  2. Complete patient section and have your ophthalmologist complete the physician section
  3. Submit with all supporting documentation and Cigna's denial letters
  4. For urgent cases, request expedited review (decision within 72 hours)

Cost: Maximum $25 filing fee (waived for financial hardship or Medicaid enrollees)

Outcome: If successful, Cigna must cover the treatment and refund the filing fee

From our advocates: We've seen many anti-VEGF denials overturned on external appeal in New York when the submission includes strong OCT evidence, detailed treatment history, and clear documentation of why the specific drug is necessary. The key is addressing each criterion in Cigna's policy directly with quantifiable clinical data.

Getting Help with Appeals

Community Health Advocates: Free assistance for New York residents

  • Phone: 888-614-5400
  • Helps with filing appeals and understanding your rights

NY DFS Consumer Services: For questions about the external appeal process

Quick Reference Checklist

Before You Start

  • Verify active Cigna coverage and benefits
  • Confirm specialty pharmacy requirements
  • Check if step therapy applies to your plan
  • Gather all prior treatment records

Clinical Documentation Required

  • Specific diagnosis with ICD-10 code
  • Current visual acuity measurements
  • OCT showing active disease
  • Complete anti-VEGF treatment history
  • Medical necessity letter from ophthalmologist

Submission Checklist

  • Use current Cigna PA form
  • Submit electronically when possible
  • Mark urgent if vision-threatening
  • Keep confirmation numbers
  • Set calendar reminder to check status

If Denied

  • Read denial letter carefully
  • File internal appeal within 180 days
  • Consider NY external appeal if internal appeal fails
  • Contact Community Health Advocates for help

Need help turning your denial into an approval? Counterforce Health specializes in transforming insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with your insurer's own rules, pulling the right clinical evidence and citations to support your case.

For complex cases or if you're facing repeated denials, Counterforce Health's automated appeal system can help identify the specific denial basis and draft compelling appeals that meet Cigna's procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage criteria and processes may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For assistance with New York insurance issues, contact the NY Department of Financial Services or Community Health Advocates.

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