Do You Qualify for Strensiq (Asfotase Alfa) Coverage by Cigna in New Jersey? Complete Decision Tree & Appeals Guide
Answer Box: Quick Start for New Jersey Cigna Members
You likely qualify if you have confirmed pediatric-onset hypophosphatasia with genetic testing (ALPL mutation) and persistently low alkaline phosphatase levels. First step today: Contact your specialist to begin prior authorization 6-8 weeks before any current approval expires. If denied, you have 180 days to appeal internally, then can request binding external review through New Jersey's IHCAP program managed by Maximus Federal Services. Success rates exceed 80% with proper documentation.
Table of Contents
- How to Use This Decision Tree
- Eligibility Triage: Do You Qualify?
- If "Likely Eligible": Document Checklist
- If "Possibly Eligible": Tests to Request
- If "Not Yet Eligible": Alternative Options
- If Denied: New Jersey Appeal Path
- Coverage Requirements at a Glance
- Common Denial Reasons & How to Fix Them
- FAQ: Cigna Strensiq Coverage in New Jersey
How to Use This Decision Tree
This guide helps you determine if you qualify for Strensiq (asfotase alfa) coverage through Cigna in New Jersey, then provides the exact steps to get approved or successfully appeal a denial.
Start here: Answer the questions in the eligibility triage section below. Based on your answers, you'll be directed to the appropriate next steps—whether that's gathering documents for approval, requesting additional testing, or preparing an appeal.
Key insight: Cigna requires prior authorization for all Strensiq prescriptions, with approval typically valid for 12 months. The process takes 3-7 business days when documentation is complete.
Eligibility Triage: Do You Qualify?
Work through these questions with your healthcare team:
Diagnosis Confirmation
Do you have confirmed hypophosphatasia with BOTH of the following?
- ✓ Genetic testing showing pathogenic ALPL gene variants
- ✓ Persistently low serum alkaline phosphatase (ALP) for your age and sex
Clinical manifestations present?
- ✓ Perinatal, infantile, or juvenile-onset symptoms (early tooth loss before age 5, delayed walking, recurrent fractures, bone pain)
- ✓ Current or historical clinical features consistent with pediatric-onset HPP
Specialist Involvement
Is your prescription from an appropriate specialist?
- ✓ Geneticist, endocrinologist, metabolic disorder specialist, or physician specializing in hypophosphatasia
Results Interpretation:
- All boxes checked = "Likely Eligible" → Go to Document Checklist
- Missing 1-2 items = "Possibly Eligible" → Go to Tests to Request
- Missing 3+ items = "Not Yet Eligible" → Go to Alternative Options
If "Likely Eligible": Document Checklist
You're ready to submit for prior authorization. Gather these documents:
Required Clinical Documentation
- Recent lab results (ALP levels within 6 months)
- Genetic testing report confirming ALPL pathogenic variants
- Clinical notes documenting HPP diagnosis and current symptoms
- Specialist consultation notes from appropriate provider type
Submission Process
- Provider submits PA via Cigna provider portal or Express Scripts system
- Timeline: 3-7 business days for complete submissions
- Approval duration: 12 months typically
- Renewal reminder: Start process 6-8 weeks before expiration
Tip: Incomplete documentation is the #1 cause of delays. Double-check all required elements before submission.
Specialty Pharmacy Coordination
Once approved, Accredo specialty pharmacy (Cigna's partner) will:
- Contact you to arrange cold-chain delivery
- Provide injection training and ongoing support
- Manage refills and renewal reminders
- Offer 24/7 clinical support
If "Possibly Eligible": Tests to Request
You may qualify but need additional documentation. Request these from your healthcare team:
Missing Genetic Testing
What to request: ALPL gene sequencing to identify pathogenic variants Timeline: 2-4 weeks for results Documentation needed: Full genetic report with variant classification
Insufficient Lab Documentation
What to request: Repeat serum ALP testing on separate occasions Timeline: Can be done at next appointment Key point: Must use age- and sex-specific reference ranges
Specialist Consultation Needed
What to request: Referral to geneticist, endocrinologist, or metabolic specialist Timeline: 2-6 weeks for appointment depending on location Documentation: Consultation notes confirming HPP diagnosis
Supportive Lab Work
Consider requesting (helpful but not required):
- Serum pyridoxal 5'-phosphate (PLP) levels
- Urine phosphoethanolamine
- Imaging studies showing bone abnormalities
Timeline to re-apply: Once you have the missing documentation, typically 4-8 weeks total.
If "Not Yet Eligible": Alternative Options
If you don't currently meet criteria, discuss these approaches with your healthcare team:
Family History Without Current Symptoms
Cigna's position: Family history alone isn't sufficient for approval Alternative approach: Document any current clinical manifestations, even subtle ones Consider: Baseline testing to establish current ALP levels for future monitoring
Adult-Onset Presentation
Challenge: Most payers restrict coverage to pediatric-onset HPP Strategy: Document any childhood symptoms or early manifestations Exception request: May be possible with comprehensive clinical justification
Prepare for Exception Requests
- Gather comprehensive clinical history including childhood symptoms
- Document functional limitations from current symptoms
- Literature review supporting treatment in your specific situation
- Specialist support with detailed medical necessity letter
If Denied: New Jersey Appeal Path
New Jersey offers excellent consumer protections through its Independent Health Care Appeals Program (IHCAP).
Internal Appeals (First Step)
Timeline: File within 180 days of denial Process: Submit to Cigna with detailed rebuttal addressing each denial reason Success rate: 80%+ for well-documented rare disease appeals
Peer-to-Peer Review
When to request: For complex cases or unclear denial reasons
Process: Your prescriber discusses case directly with Cigna medical director Advantage: Allows clinical nuance and real-time clarification
External Review (IHCAP)
Who manages: Maximus Federal Services Timeline: File within 4 months of final internal denial Decision timeframe:
- Standard cases: 45 calendar days
- Expedited (urgent): 48 hours Cost: Free to you Binding: Yes, insurer must comply with favorable decisions
How to File External Appeal
- Submit online: njihcap.maximus.com
- Required documents:
- Denial letters
- Medical records
- Physician statement
- Completed external appeal form
- For expedited review: Include provider statement explaining urgent medical need
From our advocates: "We've seen several New Jersey Cigna members successfully overturn Strensiq denials through IHCAP. The key was having the prescribing specialist write a detailed letter explaining why the patient met FDA-approved criteria, despite the initial denial. Most external reviewers are familiar with rare disease standards when given proper clinical context."
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required for all prescriptions | Cigna provider portal | Cigna PA Policy |
| Genetic Testing | ALPL pathogenic variants | Lab report | FDA Label Requirements |
| Low ALP Levels | Age/sex-adjusted reference ranges | Recent lab work | Clinical Guidelines |
| Specialist Prescription | Geneticist, endocrinologist, or metabolic specialist | Provider credentials | Cigna Coverage Criteria |
| Pediatric-Onset Documentation | Clinical evidence of childhood symptoms | Medical history | FDA Approved Indications |
| Annual Renewal | PA expires after 12 months | Cigna member portal | Express Scripts Process |
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| "Adult-onset HPP not covered" | Document childhood symptoms/early manifestations | Medical history, growth records, dental records |
| "Insufficient genetic confirmation" | Provide complete ALPL gene testing | Full genetic report with pathogenic variant classification |
| "Not medically necessary" | Address each criterion point-by-point | Clinical notes, lab results, specialist consultation |
| "Dosing above label" | Justify higher dose with clinical response data | Treatment logs, clinical assessments, specialist rationale |
| "Missing specialist consultation" | Obtain appropriate specialist involvement | Consultation notes from qualified provider |
FAQ: Cigna Strensiq Coverage in New Jersey
How long does Cigna prior authorization take in New Jersey? Typically 3-7 business days for complete submissions. Incomplete requests may take longer due to additional information requests.
What if Strensiq is non-formulary on my plan? You can request a formulary exception with clinical justification. Success rates are high for FDA-approved rare disease treatments when medical necessity is demonstrated.
Can I request expedited prior authorization? Yes, for urgent medical situations. Your prescriber must document why delays would cause serious harm to health or function.
Does step therapy apply if I tried other treatments outside New Jersey? Previous treatment history from other states counts toward step therapy requirements. Provide documentation of prior therapies and outcomes.
What happens if my appeal is denied by Cigna? You can file for external review through New Jersey's IHCAP program. This is free, binding, and has high success rates for rare diseases with proper documentation.
How much does Strensiq cost without insurance? Approximately $10,000+ per vial, with total annual costs potentially reaching $500,000-$4.9 million depending on weight-based dosing. Manufacturer assistance programs may help with coverage gaps.
Can my doctor file the external appeal for me? Yes, New Jersey allows providers to file external appeals on behalf of patients with written consent.
What if I have a self-funded employer plan? Self-funded ERISA plans follow federal rather than state appeal rules. Contact the U.S. Department of Labor for guidance on external review options.
Getting expert help with insurance appeals: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis and drafts point-by-point responses aligned to each plan's requirements, significantly improving approval rates for complex medications like Strensiq.
For additional support with Cigna prior authorizations and appeals in New Jersey, Counterforce Health can help streamline the process by ensuring all documentation meets payer-specific requirements and procedural deadlines.
Sources & Further Reading
- Cigna Strensiq Coverage Policy (PDF)
- New Jersey IHCAP External Appeals Portal
- FDA Strensiq Prescribing Information
- NJ Department of Banking and Insurance Appeals Guide
- Alexion Access Navigator Patient Support
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For official appeals procedures and current forms, refer to your plan documents and the New Jersey Department of Banking and Insurance.
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