By Counterforce Health Team in Jaypirca (pirtobrutinib) —

The Requirements Checklist to Get Jaypirca (Pirtobrutinib) Covered by Cigna in Texas: Complete Prior Authorization Guide

Answer Box: Getting Jaypirca (Pirtobrutinib) Covered by Cigna in Texas

Eligibility: Adults 18+ with relapsed/refractory mantle cell lymphoma (after BTK inhibitor) or CLL/SLL (after BTK inhibitor + BCL-2 inhibitor). Fastest path: Submit prior authorization through CoverMyMeds or call Cigna at 1-800-882-4462 with complete treatment history. First step today: Gather your diagnosis (ICD-10: C83.1 for MCL, C91.10-C91.12 for CLL), prior therapy records, and contact Accredo specialty pharmacy at 877-826-7657. Appeals deadline: 180 days from denial in Texas.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Appeals Process in Texas
  10. Common Denial Reasons & Solutions
  11. Cost Support Options
  12. FAQ

Who Should Use This Guide

This guide is designed for Texas residents with Cigna insurance who need Jaypirca (pirtobrutinib) for blood cancers. You'll benefit from this checklist if you're dealing with:

  • Relapsed mantle cell lymphoma after trying at least one BTK inhibitor
  • Chronic lymphocytic leukemia or small lymphocytic lymphoma that has returned after BTK inhibitor and BCL-2 inhibitor therapy
  • Initial prior authorization denials that need appealing with stronger documentation

Expected outcome: With proper documentation, oncology prior authorization appeals have high success rates. In Texas, external review organizations overturn approximately 68% of oncology drug denials when clinical evidence supports medical necessity.

Member & Plan Basics

Coverage Verification

Before starting the prior authorization process, confirm these basics:

  • Active Cigna coverage with current member ID
  • Plan type: Commercial, Medicare Advantage, or employer-sponsored (ERISA plans follow federal appeals rules)
  • Specialty pharmacy benefits through Express Scripts/Accredo
  • Prior authorization requirement: All Jaypirca prescriptions require PA approval
Note: Texas residents with ERISA self-funded employer plans follow federal appeals processes, not Texas state external review procedures.

Clinical Criteria Requirements

Age and Diagnosis Requirements

Requirement Details ICD-10 Code
Minimum age 18 years or older -
Mantle cell lymphoma Relapsed/refractory after ≥1 BTK inhibitor C83.1
CLL/SLL Relapsed/refractory after BTK inhibitor + BCL-2 inhibitor C91.10-C91.12, C82.1

Step Therapy Documentation

For Mantle Cell Lymphoma:

  • Documentation of at least one prior BTK inhibitor (ibrutinib, acalabrutinib, or zanubrutinib)
  • Evidence of disease progression or intolerance

For CLL/SLL:

  • Prior BTK inhibitor therapy with dates and outcomes
  • Prior BCL-2 inhibitor (typically venetoclax) with treatment duration
  • Clear documentation of failure, progression, or intolerance to both drug classes

Coding & Billing Information

Essential Codes for Prior Authorization

Code Type Code Description
ICD-10 C83.1 Mantle cell lymphoma
ICD-10 C91.10 Chronic lymphocytic leukemia, unspecified
ICD-10 C91.11 CLL in remission
ICD-10 C91.12 CLL in relapse
ICD-10 C82.1 Small lymphocytic lymphoma
HCPCS J9999 Unclassified drugs (Jaypirca billing)

Dosing Information

Standard Jaypirca dosing is 200 mg once daily (two 100-mg tablets). Include weight-based calculations and any dose modifications in your submission.

Documentation Packet Checklist

Required Clinical Documentation

Provider Notes Must Include:

  • Complete diagnosis with staging information
  • Detailed treatment history with specific dates
  • Documentation of prior BTK inhibitor therapy
  • For CLL/SLL: BCL-2 inhibitor treatment records
  • Current disease status and imaging results
  • Contraindications to alternative therapies

Medical Necessity Letter Components

Your oncologist's letter should address:

  1. Patient-specific factors: Age, performance status, comorbidities
  2. Treatment history: Specific prior therapies, durations, reasons for discontinuation
  3. Clinical rationale: Why Jaypirca is medically necessary now
  4. Alternative therapies: Why other options aren't appropriate
  5. Monitoring plan: How safety will be assessed during treatment
Clinician Corner: Include references to FDA labeling for Jaypirca's activity against C481S mutations, which cause resistance to covalent BTK inhibitors. This scientific rationale strengthens medical necessity arguments.

Supporting Attachments

  • Recent lab results (CBC, comprehensive metabolic panel)
  • Imaging studies showing current disease status
  • Pharmacy records of prior BTK inhibitor fills
  • Previous prior authorization denials (if applicable)
  • Genetic testing results (if available)

Submission Process

Step-by-Step Submission

1. Prepare Documentation (Patient/Clinic)

  • Gather all required clinical records
  • Complete medical necessity letter
  • Timeline: 2-3 business days

2. Submit Prior Authorization (Clinic)

  • Primary method: CoverMyMeds platform
  • Alternative: Call Cigna at 1-800-882-4462
  • Required fields: Complete diagnosis, treatment history, prescriber attestation
  • Timeline: Same day submission

3. Specialty Pharmacy Setup (Patient/Clinic)

  • Contact Accredo at 877-826-7657
  • Provide prescription and PA approval
  • Timeline: 1-2 business days after approval

Common Submission Errors to Avoid

  • Incomplete treatment history: Missing dates or outcomes for prior therapies
  • Wrong diagnosis codes: Using unspecified codes instead of specific ICD-10s
  • Missing prescriber attestation: Unsigned or incomplete medical necessity letters
  • Incorrect dosing: Not specifying 200 mg daily dosing
  • Wrong specialty pharmacy: Sending to non-Accredo pharmacies

Specialty Pharmacy Requirements

Accredo Specialty Pharmacy Process

Cigna requires Jaypirca to be dispensed through Accredo specialty pharmacy. Here's the transfer process:

1. Initial Setup

  • Call Accredo at 877-826-7657
  • Provide PA approval number
  • Verify shipping address and insurance

2. Prescription Transfer

  • Accredo coordinates with your oncology clinic
  • No patient action required for transfers
  • Timeline: 24-48 hours for first shipment

3. Ongoing Refills

  • Automatic refill program available
  • Cold-chain shipping included
  • Cost: Covered under specialty pharmacy benefits
Tip: Accredo provides dedicated oncology pharmacists who can answer questions about drug interactions and side effects.

After Submission: What to Expect

Review Timeline

Review Type Timeline When to Use
Standard Up to 72 hours Routine requests
Urgent 24 hours Clinical urgency documented
Complex Extended review Additional documentation needed

Status Tracking

  • Confirmation number: Record PA reference number
  • Status checks: Call Cigna member services weekly
  • Documentation: Keep copies of all submissions

What to Record:

  • PA submission date and confirmation number
  • Representative names and call reference numbers
  • Any additional documentation requests
  • Approval or denial date and details

Appeals Process in Texas

Internal Appeals Timeline

Level 1 Appeal: Must be filed within 180 calendar days of initial denial

  • Review time: 30 days for pre-service requests
  • Required: Written appeal with supporting documentation
  • Outcome: Approval, denial, or request for more information

Level 2 Appeal: Must be filed within 60 calendar days of Level 1 denial

  • Review time: 30 days
  • Higher-level review: Different medical reviewers
  • Final internal decision: Triggers external review rights

External Review in Texas

For medical necessity denials, Texas law provides Independent Review Organization (IRO) review:

  • Eligibility: Medical necessity or experimental treatment denials
  • Timeline: Request within 4 months of final internal denial
  • Process: IRO reviews clinical evidence independently
  • Binding decision: If IRO approves, Cigna must cover the treatment

Texas Department of Insurance Resources:

  • Consumer hotline: 1-800-252-3439
  • TDI IRO information: 1-866-554-4926
  • Office of Public Insurance Counsel: 1-877-611-6742

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient prior therapy Submit complete treatment records Pharmacy records, clinic notes with dates
Missing step therapy Document BCL-2 inhibitor trial for CLL/SLL Venetoclax treatment history and outcomes
Safety concerns Address monitoring plan Detailed safety monitoring protocol
Non-formulary status Request formulary exception Medical necessity for specific agent
Quantity limits Justify standard dosing FDA labeling reference for 200 mg daily

Strengthening Your Appeal

When appealing a denial, include:

  • Peer-reviewed literature supporting Jaypirca use post-BTK inhibitor
  • FDA labeling showing activity against resistant mutations
  • Professional guidelines from NCCN or ASH (if available)
  • Patient-specific factors making alternatives inappropriate

Counterforce Health specializes in turning insurance denials into evidence-backed appeals by analyzing the specific denial reasons and crafting targeted responses that align with each payer's policies and clinical criteria.

Cost Support Options

Financial Assistance Programs

Lilly Cares Foundation

  • Income-based medication assistance
  • Application through healthcare provider
  • Eligibility: Varies by household income

Jaypirca Savings Program

  • Copay assistance for commercial insurance
  • May reduce out-of-pocket costs significantly
  • Limitations: Not available for government insurance

State Resources

  • Texas has limited state drug assistance programs
  • Check with local cancer organizations for additional support

Insurance Navigation

Given Texas's high uninsured rate (16-18%), many residents struggle with coverage. If you're uninsured:

  • Marketplace plans: Open enrollment or special enrollment periods
  • Medicaid: Limited in Texas due to non-expansion
  • Hospital financial assistance: Many cancer centers offer payment plans

FAQ

How long does Cigna prior authorization take in Texas? Standard review takes up to 72 hours, urgent requests within 24 hours. Complex cases may require additional documentation and extended review time.

What if Jaypirca is non-formulary on my plan? Request a formulary exception through the standard prior authorization process. Include medical necessity documentation showing why preferred alternatives aren't appropriate.

Can I request an expedited appeal in Texas? Yes, if delays would jeopardize your health. You can request expedited internal and external reviews simultaneously for urgent cases.

Does step therapy apply if I failed BTK inhibitors outside Texas? Yes, prior therapy documentation from any state counts toward step therapy requirements. Ensure complete records are submitted.

What happens if my appeal is denied? For state-regulated plans, you can request external review through an Independent Review Organization. For ERISA plans, federal appeals processes apply.

How much does Jaypirca cost without insurance? Cash prices typically range from $22,500-$26,000 per month. Patient assistance programs may help reduce costs.

From our advocates: We've seen many Jaypirca appeals succeed when clinicians include specific genetic testing results showing BTK resistance mutations. Even without formal testing, documenting rapid progression on prior BTK inhibitors strengthens the medical necessity argument. The key is painting a complete picture of why this specific patient needs this specific drug at this specific time.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan details. Always consult your healthcare provider about treatment options and work with your insurance company directly for coverage determinations. For personalized assistance with complex appeals, consider consulting with organizations like Counterforce Health that specialize in insurance coverage advocacy.

Need Help? Contact the Texas Department of Insurance consumer hotline at 1-800-252-3439 or visit tdi.texas.gov for additional resources on appealing insurance denials in Texas.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.