Daa Retreatment Vosevi denied as non-formulary by Cigna?

Cigna's specific coverage criteria for daa retreatment vosevi are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Denied Vosevi as Non-Formulary

A non-formulary denial means Vosevi (sofosbuvir/velpatasvir/voxilaprevir) is not included on Cigna's preferred drug list for your specific benefit plan — or is placed on a tier that requires a formulary exception before it will be covered at any cost-sharing level. For retreatment DAA therapy, non-formulary placement is common because Vosevi is a specialty drug; however, this does not mean it is uncoverable. Formulary exception requests — and appeals when exceptions are denied — are the correct pathway.

## Why This Denial Is Appealable

Cigna is required under its plan documents and applicable federal law to maintain a formulary exception process. The grounds for exception include: (1) no formulary alternative is clinically appropriate for this patient, (2) the formulary alternative has been tried and failed, or (3) the formulary alternative is contraindicated or otherwise clinically inferior given the patient's specific circumstances. For Vosevi specifically, if the patient has previously failed treatment that included a formulary alternative, that prior failure is itself the clinical basis for the exception.

## Federal Appeal Framework

• Formulary exception request: File this first. Cigna's formulary exception process runs in parallel with the formal appeal and may resolve the issue faster.
• Internal appeal (ACA §2719 / ERISA §503): File simultaneously with the exception request. The denial of a formulary exception is itself an adverse benefit determination that triggers full appeal rights.
• External review: Available after a final internal denial under ACA §2719. File within approximately four months. Expedited review available when medically urgent.

## Concrete Appeal Steps

1. Identify which drugs Cigna lists as formulary alternatives for hepatitis C retreatment under your plan. 2. For each formulary alternative, document why it is not clinically appropriate: prior failure, genotype-specific limitations, resistance profile, or prescriber judgment that it is clinically inferior. 3. Have your prescriber write a formulary exception request letter that addresses the clinical reason Vosevi is necessary and why formulary alternatives are inadequate. 4. Submit the exception request and internal appeal together with supporting documentation. 5. If denied, escalate to external review.

## Documentation to Gather

• Cigna formulary alternative list: print the relevant section of the plan's drug list
• Prior treatment records: documents prior DAA therapy with dates and outcomes
• Prescriber exception letter: explains clinical need for Vosevi and why formulary alternatives are not appropriate for this patient
• Current HCV RNA, genotype, and resistance testing if performed
• Liver disease staging documentation

## Criteria-Mapping Structure

For a formulary exception appeal, the mapping structure should address each available formulary alternative in turn. For each alternative: (a) state the drug name, (b) state why it is not appropriate for this patient (prior failure, resistance, clinical scenario), and (c) cite the chart evidence. Then state the positive case for Vosevi: the FDA-approved retreatment indication and the AASLD/IDSA guideline support. This structure answers the question a reviewer will ask — "why can't the patient use a formulary option?" — before the reviewer has to ask it.