By Counterforce Health Team in Tracleer (bosentan) —

The Requirements Checklist to Get Tracleer (Bosentan) Covered by Cigna in Ohio

Answer Box: Getting Tracleer (Bosentan) Covered by Cigna in Ohio

Eligibility: Patients with WHO Group 1 pulmonary arterial hypertension confirmed by right heart catheterization. Fastest path: Complete REMS enrollment, gather step therapy documentation, and submit prior authorization through CoverMyMeds or Cigna provider portal. First step today: Contact your pulmonologist or cardiologist to initiate REMS program enrollment at BosentanREMSProgram.com (866-359-2612) while gathering documentation of failed preferred therapies like ambrisentan or sildenafil.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission
  9. Common Denial Prevention
  10. Printable Checklist
  11. Appeals Process for Ohio
  12. FAQ

Who Should Use This Checklist

This checklist applies if you're a Cigna member in Ohio seeking coverage for Tracleer (bosentan) for WHO Group 1 pulmonary arterial hypertension. You'll need a pulmonologist or cardiologist to prescribe, as only these specialists can prescribe Tracleer under Cigna plans.

Expected outcome: With complete documentation, most prior authorizations are approved within 15 business days. If denied initially, Ohio's external review process gives you a second chance with independent medical experts.

Member & Plan Basics

Coverage Verification

  • Active Cigna coverage confirmed through member portal or 1-800-Cigna24
  • Specialty pharmacy benefit active (typically managed through Express Scripts/Accredo)
  • Deductible status checked (specialty drugs may have separate deductibles)
  • Prior authorization requirement confirmed via Cigna formulary

Plan Type Considerations

Commercial plans typically require step therapy, while Medicare Advantage may have different criteria. Self-funded employer plans follow federal ERISA rules but often mirror Ohio's appeal processes voluntarily.

Clinical Criteria Requirements

Diagnosis Requirements

  • WHO Group 1 PAH confirmed by right heart catheterization
  • Hemodynamic parameters documented:
    • Mean pulmonary artery pressure ≥25 mmHg
    • Pulmonary capillary wedge pressure ≤15 mmHg
    • Pulmonary vascular resistance >3 Wood Units
  • WHO functional class assessment completed
  • 6-minute walk test results documented

Step Therapy Documentation

Cigna requires documentation of failed trials or contraindications to preferred agents:

  • Ambrisentan trial (dates, doses, outcomes, reasons for discontinuation)
  • Sildenafil or tadalafil trial (if applicable)
  • Contraindication documentation if trials weren't attempted

REMS Program Requirements

  • Patient enrollment completed at BosentanREMSProgram.com or 866-359-2612
  • Prescriber REMS certification confirmed
  • Pharmacy enrollment verified with dispensing pharmacy

Coding Requirements

ICD-10 Codes

Use the appropriate code for your specific PAH type:

  • I27.0 - Primary pulmonary hypertension (idiopathic PAH)
  • I27.21 - Secondary pulmonary arterial hypertension
  • Associated condition codes if applicable (congenital heart disease, HIV, etc.)

Additional Coding

  • NDC number for Tracleer confirmed
  • Quantity and days supply specified
  • Units per dose documented

Documentation Packet

Provider Note Elements

Your specialist's clinical note must include:

  • Complete PAH diagnosis with hemodynamic data
  • Treatment history with specific dates and outcomes
  • Clinical rationale for Tracleer specifically
  • Monitoring plan for monthly liver function tests
  • Contraception plan for women of childbearing age (if applicable)

Letter of Medical Necessity Components

  • Patient demographics and insurance information
  • Clinical presentation and symptom severity
  • Diagnostic test results supporting PAH diagnosis
  • Prior treatment failures with specific details
  • Medical necessity justification citing guidelines
  • Monitoring protocol outlined

Required Attachments

  • Right heart catheterization report
  • Echocardiogram results
  • 6-minute walk test documentation
  • Prior medication trial records
  • Laboratory results (baseline liver function)
  • REMS enrollment confirmation

Submission Process

Electronic Submission (Preferred)

Your prescriber should submit through:

  • CoverMyMeds (most common, often provides immediate decisions)
  • EviCore by Evernorth (Express Scripts-specific platform)
  • Surescripts CompletEPA (free, connects to all PBMs)
  • EHR ePrescribing (fastest if available)

Alternative Submission

  • Phone submission to Cigna at 1-800-882-4462
  • Fax submission (verify current fax number with Cigna)

Required Form Fields

Common rejection causes include:

  • Correct patient ID number
  • Accurate prescriber NPI
  • Complete diagnosis codes
  • Proper drug NDC/name
  • Quantity and days supply

Specialty Pharmacy Coordination

Preferred Vendors

Cigna typically uses:

  • Accredo Specialty Pharmacy
  • Express Scripts Specialty Pharmacy
  • Verify your plan's preferred network

Transfer Steps

  • Prior authorization approved before pharmacy transfer
  • Patient enrollment completed with specialty pharmacy
  • Shipping preferences confirmed
  • Copay assistance programs explored

Shipment Verification

  • Delivery address confirmed
  • Temperature-controlled shipping arranged if needed
  • Signature requirements understood

After Submission

Tracking Your Request

  • Confirmation number recorded from submission
  • Status check schedule established (every 3-5 business days)
  • Contact information for follow-up saved

Timeline Expectations

  • Standard review: 15 business days
  • Expedited review: 72 hours (if medically urgent)
  • Approval notification: Usually by phone and portal

What to Record

  • Submission date and method
  • Reference/confirmation numbers
  • Follow-up call dates and outcomes
  • Any additional information requested

Common Denial Prevention

Five Critical Pitfalls to Avoid

  1. Incomplete REMS enrollment
    • Fix: Ensure patient, prescriber, AND pharmacy are all enrolled before submission
  2. Missing step therapy documentation
    • Fix: Provide detailed records of preferred drug trials with specific dates, doses, and outcomes
  3. Inadequate hemodynamic documentation
    • Fix: Include complete right heart catheterization report with all required parameters
  4. Wrong specialist type
    • Fix: Ensure prescription comes from board-certified pulmonologist or cardiologist
  5. Insufficient monitoring plan
    • Fix: Document monthly liver function test schedule and responsibility
From our advocates: We've seen cases where patients received approval after initially being denied for "incomplete REMS enrollment" - the issue was that while the patient and prescriber were enrolled, the specialty pharmacy hadn't completed their enrollment. Always verify all three parties are enrolled before submission.

Printable Checklist

Pre-Submission Checklist

Patient Information

  • Active Cigna coverage verified
  • Specialty pharmacy benefit confirmed
  • REMS enrollment completed

Clinical Documentation

  • WHO Group 1 PAH diagnosis confirmed by RHC
  • Step therapy trials documented
  • Specialist prescriber (pulmonology/cardiology)
  • Monitoring plan established

Submission Ready

  • All attachments gathered
  • Electronic submission method selected
  • Confirmation number received
  • Follow-up schedule planned

Appeals Process for Ohio

If your initial request is denied, Ohio provides robust appeal rights:

Internal Appeals with Cigna

  • Level 1: File within 180 days of denial
  • Level 2: Available if Level 1 denied
  • Timeline: 30 days standard, 72 hours expedited
  • Submission: Through Cigna member portal or mail

Ohio External Review

If Cigna denies your internal appeals:

For specialized help with complex appeals, platforms like Counterforce Health help patients and clinicians turn insurance denials into evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create targeted rebuttals aligned with payer requirements.

FAQ

How long does Cigna prior authorization take for Tracleer in Ohio? Standard review takes 15 business days. Expedited review (for urgent medical needs) takes 72 hours.

What if Tracleer is non-formulary on my Cigna plan? You can request a formulary exception with clinical documentation showing medical necessity and why preferred alternatives aren't appropriate.

Can I request an expedited appeal if denied? Yes, if delays would seriously jeopardize your health. Document the urgent medical need in your appeal request.

Does step therapy apply if I failed preferred drugs outside Ohio? Yes, trials from any location count toward step therapy requirements if properly documented.

What's the success rate for Tracleer appeals in Ohio? While specific statistics aren't published, external review provides independent medical expert assessment, which often favors patients with strong clinical documentation.

Can I get help with my appeal? Yes, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526 for guidance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies may vary by plan and change over time.

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