By Counterforce Health Team in Firdapse (amifampridine) —

Do You Qualify for Firdapse (Amifampridine) Coverage by Cigna in New Jersey? Decision Tree & Next Steps

Quick Answer: Your Path to Firdapse Coverage

Most likely eligible: If you have confirmed LEMS with EMG evidence, are ≥6 years old, have no seizure history, and a neurologist's prescription. First step: Have your neurologist submit prior authorization through CoverMyMeds with complete diagnostic documentation. If denied: Cigna allows internal appeals within 180 days, followed by New Jersey's IHCAP external review through Maximus Federal Services. Timeline: PA decision typically within 15 business days; appeals 45-72 hours depending on urgency.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Your Appeal Path
  7. New Jersey External Review (IHCAP)
  8. Common Denial Reasons & Fixes
  9. Cost Savings and Support
  10. FAQ

How to Use This Decision Tree

This guide helps patients with Lambert-Eaton myasthenic syndrome (LEMS) navigate Cigna's prior authorization process for Firdapse (amifampridine) in New Jersey. Start with the eligibility triage below, then follow the appropriate pathway based on your situation.

Firdapse is the only FDA-approved treatment for LEMS in patients ≥6 years old. At approximately $375,000 annually, prior authorization is standard across all Cigna plans, but approval rates are high when documentation is complete.

Eligibility Triage: Do You Qualify?

Likely Eligible ✅

You probably qualify if you meet ALL of these criteria based on Cigna's Amifampridine Products Prior Authorization Policy:

  • Age: 6 years or older
  • Diagnosis: Confirmed LEMS with either:
    • Positive anti-P/Q-type voltage-gated calcium channel antibodies, OR
    • EMG showing ≥60% CMAP increment after exercise or high-frequency stimulation
  • Prescriber: Neurologist or neuromuscular specialist (or consultation documented)
  • Safety: No history of seizures
  • Dose: Within FDA limits (≤100 mg/day)

Possibly Eligible ⚠️

You might qualify with additional documentation if:

  • LEMS diagnosis is suspected but not fully confirmed
  • You're seronegative for VGCC antibodies but have classic clinical features
  • You have controlled seizure history with neurologist approval
  • Previous treatments haven't been adequately documented

Not Yet ❌

You'll need to address these issues first:

  • Under 6 years old (off-label use requires special justification)
  • No clear LEMS diagnosis or supporting tests
  • Active, uncontrolled seizure disorder
  • No neurologist involvement

If "Likely Eligible": Document Checklist

Your neurologist should submit these documents through Accredo specialty pharmacy or directly to Cigna:

Required Documentation

Document Details Where to Get It
Prior Authorization Form Cigna-specific PA form Cigna provider portal
Neurology Consult Note Must state LEMS diagnosis clearly Your neurologist
EMG/NCS Report Show CMAP increment ≥60% Neuromuscular lab
VGCC Antibody Results Positive or documented negative Lab (Quest, LabCorp)
Medical History Confirm no seizure history Your neurologist
Prescription Within 100 mg/day limit Your neurologist

Submission Process

  1. Neurologist submits PA through CoverMyMeds or Cigna provider portal
  2. Accredo coordinates if using specialty pharmacy (recommended)
  3. Decision timeline: 15 business days for standard review, 72 hours for expedited
  4. Track status via myCigna app or call 1-800-835-3784
Tip: Request expedited review if LEMS symptoms are rapidly worsening or affecting safety (falls, respiratory function).

If "Possibly Eligible": Tests to Request

Work with your neurologist to complete diagnostic workup:

Additional Testing Needed

  • Repetitive nerve stimulation (RNS): Focus on post-exercise facilitation
  • Single-fiber EMG: If standard EMG is borderline
  • Complete neurological exam: Document weakness pattern, reflexes, autonomic symptoms
  • Cancer screening: Chest CT or PET scan (40-60% of LEMS is paraneoplastic)

Timeline to Reapply

  • Allow 2-4 weeks for test completion
  • Resubmit PA within 30 days of initial denial for fastest processing
  • Include letter explaining additional evidence obtained

If "Not Yet": Alternatives and Exceptions

Immediate Treatment Options

  • Pyridostigmine (Mestinon): First-line symptomatic treatment while awaiting approval
  • IVIG or plasmapheresis: For severe cases
  • Manufacturer assistance: Catalyst Patient Support Program

Exception Request Strategy

For off-label or complex cases:

  1. Medical necessity letter emphasizing severity and lack of alternatives
  2. Literature review supporting off-label use
  3. Specialist attestation of risk-benefit analysis
  4. Consider compassionate use through manufacturer

If Denied: Your Appeal Path

Cigna offers multiple appeal levels with specific timelines:

Internal Appeals (Required First)

Level Timeline How to Submit
First Level 180 days from denial Cigna appeals portal or call 1-800-835-3784
Second Level 60 days from first denial Same portal; request peer-to-peer review
Expedited 72 hours For urgent medical situations

Required Appeal Documents

  • Copy of original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Any new clinical evidence
  • Physician attestation of ongoing need

Peer-to-Peer Review Strategy

When requesting physician-to-physician review:

Key talking points for your neurologist:

  • "Patient meets all criteria in your Firdapse policy"
  • Specific EMG findings and VGCC antibody status
  • Functional impact without treatment
  • Safety assessment completed
From our advocates: We've seen denials overturned during peer-to-peer calls when the reviewing physician realizes the patient clearly meets published criteria. The key is having your neurologist reference Cigna's own policy point-by-point during the conversation.

New Jersey External Review (IHCAP)

If Cigna upholds the denial after internal appeals, New Jersey residents can request external review through the Independent Health Care Appeals Program (IHCAP).

IHCAP Process

  1. Eligibility: Fully insured NJ plans (not self-funded employer plans)
  2. Deadline: 4 months from final Cigna denial
  3. Submission: Direct to Maximus Federal Services
  4. Timeline: 45 days for standard review, 48 hours for expedited
  5. Cost: Free to patient; insurer pays all fees

How to File

  • Complete IHCAP external appeal forms
  • Include all medical records and denial letters
  • Sign medical records release
  • Submit electronically when possible

Success Factors

External reviews often favor patients when:

  • Clear medical necessity is demonstrated
  • Plan's own criteria are met
  • Complete clinical documentation is provided
  • Specialist strongly supports the request

For assistance, call the IHCAP hotline at 1-888-393-1062.

Common Denial Reasons & Fixes

Denial Reason How to Fix Documents Needed
"Insufficient LEMS diagnosis" Submit complete EMG report highlighting increment EMG/NCS with specific CMAP values
"No specialist involvement" Add neurology consult note Board-certified neurologist evaluation
"Safety concerns" Document seizure history assessment Neurology note confirming no seizure risk
"Dose exceeds limits" Revise prescription to ≤100 mg/day Updated prescription within FDA limits
"Not medically necessary" Emphasize functional impact and failed alternatives Medical necessity letter with outcomes

Cost Savings and Support

Financial Assistance Programs

Specialty Pharmacy Benefits

Cigna members get Firdapse through Accredo specialty pharmacy, which provides:

  • 24/7 clinical support
  • Home delivery at no extra cost
  • Adherence monitoring and refill reminders
  • Coordination with your care team

Frequently Asked Questions

How long does Cigna prior authorization take for Firdapse? Standard review takes 15 business days. Expedited review (for urgent situations) takes 72 hours. You can track status through the myCigna app.

What if Firdapse isn't on my Cigna formulary? Firdapse requires prior authorization on most Cigna plans regardless of formulary status. Non-formulary drugs may have higher copays but are still coverable with approval.

Can I get expedited review in New Jersey? Yes, both Cigna internal appeals and IHCAP external reviews offer expedited pathways when delays could seriously harm your health.

What happens if I move from another state to New Jersey? Your Cigna coverage terms remain the same, but you gain access to New Jersey's IHCAP external review process if needed.

Does step therapy apply to Firdapse? Cigna's policy doesn't require specific step therapy, but they may ask about previous treatments like pyridostigmine or immunotherapy.

How often do I need reauthorization? Initial approvals are typically for 3 months, then 12-month renewals with documentation of continued benefit.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttal letters. Our platform analyzes denial reasons and drafts point-by-point responses aligned with each plan's specific criteria, significantly improving approval rates for complex medications like Firdapse.

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 about treatment decisions and your insurance company about specific coverage details. For questions about New Jersey insurance regulations, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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