OFATUMUMAB (Kesimpta) prior authorization at Cigna
Submission criteria, P2P prep, and appeal path if denied — for prescribers and PA staff
Cigna requires CD20-directed Cytolytic Antibody prior-authorization documentation for OFATUMUMAB (Kesimpta): a diagnosis with ICD-10 code, documented step-therapy history, and prescriber attestation of medical necessity. Standard PA decisions return in 30 days; if denied, prescribers and members have 180 days to appeal.
The PA criteria you'll need to meet
Cigna reviews OFATUMUMAB (Kesimpta) prior authorizations against its medical policy for CD20-directed Cytolytic Antibody. Cigna-specific context: Sold its Medicaid Advantage book to HCSC in 2023. Express Scripts (PBM) is Cigna-owned. Frequent class-action litigation around mental health parity.
Documentation packet checklist
- Chart note with diagnosis (ICD-10 code) and clinical severity markers
- Documented failure of, contraindication to, or intolerance of step-therapy alternatives in CD20-directed Cytolytic Antibody
- Prior treatment history including dosing, duration, and reason for discontinuation
- Relevant labs, imaging, or assessment scores supporting medical necessity
- Prescriber attestation linking the FDA-approved indication to the patient's presentation
- Cigna's medical policy URL referenced in the cover letter
Cigna's common denial patterns
Pre-empting these patterns in the initial submission cuts rework and shortens time-to-approval:
- Mental health parity violations
- Step therapy
- Specialty drug prior auth
- OON balance billing disputes
OFATUMUMAB (Kesimpta)-specific denial patterns and context
Across payers (not just Cigna), OFATUMUMAB (Kesimpta)draws a distinct set of denial reasons rooted in the drug's label, REMS, and competitive landscape:
- Step therapy requiring oral DMT first
- Step therapy requiring ocrelizumab first within anti-CD20 class
- Self-administration concerns
- Specialty pharmacy network restriction
Brand: Kesimpta. Anti-CD20 monoclonal antibody for relapsing MS. Self-administered monthly subQ — distinct positioning vs ocrelizumab (IV every 6 months).
Manufacturer patient-assistance program: Novartis Patient Assistance Foundation — relevant when a Cigna denial sticks and the patient needs bridge access while appealing.
How Cigna approaches Biologic drugs (mAbs and biosimilars) PAs
Cigna's Biologic drugs (mAbs and biosimilars) reviewer typically anchors OFATUMUMAB (KESIMPTA) prior-auth decisions on step therapy and specialty drug prior auth. Pharmacy-benefit review for OFATUMUMAB (KESIMPTA) at Cigna is routed through Express Scripts (in-house since the 2018 acquisition). The 30-day standard review window starts when the prior-authorization request is received with all required documentation — incomplete packets pause the clock and add 5-10 days to time-to-approval, after which the 180-day internal-appeal window begins from the denial date. Cigna's utilization-management vendor (Carelon, eviCore, OptumRx, or in-house) sets the step-therapy ladder — appeals that cite ACR, AAD, or AGA guideline language directly to the medical director shorten escalation. Cigna is domiciled in CT, so unresolved appeals escalate to the CT insurance department's external-review program for fully-insured policies (self-funded ERISA plans route to the DOL EBSA instead). Sold its Medicaid Advantage book to HCSC in 2023.
If the PA is denied
Cigna gives prescribers and members 180 days to file an internal appeal. Standard appeal decisions return within 30 days. Submit through the provider portal (https://cignaforhcp.cigna.com) with the same packet plus a peer-reviewed citation supporting OFATUMUMAB (Kesimpta)for the patient's indication.
Helping a patient appeal the denial directly? See the consumer guide: How to appeal a Cigna denial on DenialHelp.
Contact Cigna
- Provider portal: https://cignaforhcp.cigna.com
Frequently asked questions
What documentation does Cigna need for OFATUMUMAB (Kesimpta) prior auth?
Cigna's typical PA packet for OFATUMUMAB (Kesimpta): (1) chart note documenting the indication and prior-treatment failures, (2) supporting lab/imaging where indicated, (3) prescriber attestation that step-therapy alternatives were tried or contraindicated, (4) FDA-approved indication mapped to ICD-10 diagnosis. For CD20-directed Cytolytic Antibody, expect clinical-criteria documentation specific to this class.
What's the turnaround time at Cigna?
Standard OFATUMUMAB (Kesimpta) PA decisions at Cigna: 30 days. Urgent / expedited (member's life or function at risk): 72 hours under 45 CFR §147.136.
What does Cigna most often reject OFATUMUMAB (Kesimpta) for?
Across Cigna's book the common rejection patterns include: Mental health parity violations; Step therapy; Specialty drug prior auth. For OFATUMUMAB (Kesimpta) specifically, expect step-therapy challenges and indication-restriction reviews when the use is at the edge of the FDA label or off-label.
What prior failures does Cigna typically require before approving OFATUMUMAB (KESIMPTA)?
Cigna's biologics step-therapy ladder for most indications begins with a conventional DMARD (methotrexate, sulfasalazine, leflunomide) or topical/inhaled first-line, then a step-1 biologic (typically a TNF inhibitor or adalimumab biosimilar), then the requested agent. Document trial duration (≥12 weeks for most biologics), dosing reached, and reason for discontinuation (inadequate response by disease-activity score, intolerance, or contraindication). For OFATUMUMAB (KESIMPTA), attach the specific disease-activity instrument Cigna accepts (e.g., DAS28, PASI 75, HBI, Mayo) — appeals with raw symptom narrative but no scored instrument carry higher denial rates. Pharmacy-benefit handling is routed through Express Scripts (in-house since the 2018 acquisition). External-review escalation for Cigna fully-insured policies sits with the CT insurance department.
How do I prep for a peer-to-peer with Cigna on OFATUMUMAB (Kesimpta)?
Lead with the FDA-approved indication and the specific clinical criteria the policy lists. Have the patient's chart open, document number, and policy URL on screen. State your name and credentials, the policy number, the indication, and the documented failures of step-therapy alternatives. Keep notes — if the P2P reviewer overturns, get the decision in writing.
Related PA criteria
Generate the OFATUMUMAB (Kesimpta) PA packet
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