By Counterforce Health Team in Cresemba (isavuconazole) —

How Long Does It Take to Get Cresemba (isavuconazole) Approved by Cigna in New Jersey? Complete Timeline & Appeal Guide

Answer Box: Getting Cresemba Approved by Cigna in New Jersey

Timeline: Cigna typically approves Cresemba (isavuconazole) within 2-5 business days after receiving complete documentation. Fastest path: Submit prior authorization through your doctor's office with complete clinical records showing invasive aspergillosis or mucormycosis diagnosis, infectious disease consultation, and documentation of why alternatives like voriconazole aren't suitable. First step today: Call your prescribing physician to request they initiate the PA process and gather all required documentation listed below.

Table of Contents

  1. What Affects Cresemba Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeal Timeline & Process
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips for Faster Approval

What Affects Cresemba Approval Timing

Several factors influence how quickly Cigna approves your Cresemba prior authorization in New Jersey:

Benefit Type & Plan Structure

  • Commercial plans through Express Scripts: 2-5 business days
  • Medicare Advantage: Similar timeline but may require additional documentation
  • Self-funded employer plans: May follow different criteria

Complexity of Clinical Criteria Cigna requires specific documentation for Cresemba approval:

  • Confirmed invasive aspergillosis or invasive mucormycosis diagnosis
  • Infectious disease specialist consultation
  • Documentation of voriconazole failure/intolerance (for aspergillosis)
  • Patient age ≥6 years and weight ≥16 kg for pediatric cases

Completeness of Documentation The most common cause of delays is incomplete submissions. Cigna's coverage policy requires comprehensive clinical records upfront.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before your doctor submits the PA request, gather these materials:

Clinical Documentation Required:

  • Confirmed diagnosis of invasive aspergillosis or mucormycosis (pathology/culture reports)
  • Infectious disease consultation notes
  • Previous antifungal therapy records (doses, duration, outcomes)
  • Reason for discontinuation of standard therapies
  • Current lab values and imaging results
  • Treatment plan with FDA-approved dosing (372 mg loading dose q8h × 6, then 372 mg daily)

Administrative Information:

  • Patient insurance card and member ID
  • Prescriber NPI and contact information
  • Pharmacy information (if using specialty pharmacy)
  • ICD-10 codes for diagnosis
Tip: Contact Astellas Pharma's Cresemba Support Solutions for benefits verification assistance, though they cannot provide clinical documentation.

Submission to Initial Review (1-5 Days)

How Cigna Reviews PA Requests

Standard Timeline: Express Scripts completes most coverage reviews within 2 business days of receiving complete information, with a maximum of 5 business days per Cigna's standard policy.

What Reviewers Check First:

  1. FDA-approved indication match
  2. Age and weight requirements
  3. Specialist consultation documentation
  4. Prior therapy attempts and outcomes
  5. Clinical rationale for Cresemba specifically

Submission Methods:

  • Online: CoverMyMeds portal or EHR integration (fastest)
  • Fax: Provider-specific fax numbers (confirm current number)
  • Phone: For urgent requests requiring expedited review

Expedited Review Option

For urgent cases, Cigna offers expedited review completed within 24 hours when the patient's condition may seriously jeopardize life or health. Your physician must justify the urgent medical need.

Additional Information Requests (1-7 Days)

If Cigna requests additional information, respond quickly to avoid delays:

Common Information Requests:

  • More detailed specialist consultation notes
  • Laboratory results confirming fungal infection
  • Clearer documentation of prior therapy failures
  • Dosing rationale or treatment duration

How to Respond Quickly:

  • Submit via the same method as original request
  • Include the original PA reference number
  • Provide complete documentation rather than partial responses
Note: Each round of back-and-forth can add 2-3 business days to the approval timeline.

Decision Window & Outcomes

Typical Approval Outcomes

Approved: Coverage authorized for up to 6 months per Cigna's policy Denied: Common reasons include insufficient documentation of diagnosis or lack of specialist consultation Conditional Approval: May require specific monitoring or dosing modifications

Reading Your Approval Letter

Your approval letter will specify:

  • Coverage duration (typically up to 6 months)
  • Quantity limits per fill
  • Any special requirements for renewal
  • Pharmacy restrictions (may require specialty pharmacy)

If Denied: Appeal Timeline & Process

Cigna Internal Appeals in New Jersey

Timeline: You have 180 days from the denial date to file an internal appeal with Cigna.

Standard Appeal Process:

  • Level 1: 30 days for pre-service appeals, 60 days for post-service
  • Level 2: Available if Level 1 is denied
  • Expedited Appeals: 72 hours for urgent cases

Where to Submit Appeals:

  • Commercial Plans: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Online: Through Cigna provider or member portal

New Jersey External Review

After exhausting Cigna's internal appeals, New Jersey offers an excellent external review program through the Independent Health Care Appeals Program (IHCAP).

Key Details:

  • Timeline: 4 months (180 days) from final internal denial
  • Cost: Free to patients
  • Review Entity: Maximus Federal Services (contracted by NJ)
  • Decision Timeline: 45 days for standard review, expedited for urgent cases
  • Success Rate: External reviews nationwide overturn approximately 40-55% of insurer denials

IHCAP Contact: 1-888-393-1062

From our advocates: We've seen cases where thorough documentation of the infectious disease consultation and clear explanation of why voriconazole wasn't suitable led to successful appeals, even after initial denials. The key is addressing Cigna's specific denial reasons point by point with clinical evidence.

Renewal Cycles & Reauthorization

When Reauthorization Is Needed

Cresemba approvals typically last up to 6 months. Your doctor will need to submit a renewal request before expiration, including:

  • Updated clinical assessment
  • Treatment response documentation
  • Continued medical necessity justification
  • Any changes in condition or therapy

Renewal Timeline: Start the renewal process 30 days before expiration to avoid treatment interruptions.

What Speeds Up Renewals

  • Proof of prior coverage
  • Documentation of treatment response
  • Continued specialist oversight
  • No changes to dosing or indication

Timeline Visual & Milestones

Milestone Timeline Key Actions Potential Delays
Pre-submission 0-2 days Gather documentation, verify benefits Missing clinical records
PA submission Day 0 Doctor submits complete request Incomplete forms
Initial review 1-2 days Cigna medical review begins Additional info requests
Decision 2-5 days Approval/denial notification sent Complex cases may take longer
If denied 0-180 days Internal appeal window Missing appeal deadlines
External review Up to 45 days NJ IHCAP review process Incomplete appeal documentation

Time-Saving Tips for Faster Approval

For Patients

  1. Contact your doctor early - Don't wait until you're out of current medication
  2. Gather insurance information - Have your member ID and pharmacy details ready
  3. Ask about expedited review - If your condition is urgent, request 24-hour processing
  4. Use specialty pharmacy - May have established workflows with Cigna

For Clinicians

  1. Submit complete documentation upfront - Avoid back-and-forth requests
  2. Use electronic submission - CoverMyMeds or EHR integration is fastest
  3. Include peer-reviewed evidence - Support your clinical rationale with literature
  4. Request peer-to-peer review - For complex cases, speak directly with Cigna's medical director

Leveraging Technology

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to Cigna's own rules. For Cresemba cases, this can significantly reduce the time spent on appeals and improve success rates.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cresemba prescriptions Cigna formulary Coverage Policy
Age/Weight Limits ≥6 years old, ≥16 kg for pediatric FDA labeling FDA Access Data
Specialist Requirement Infectious disease consultation PA form Cigna PA criteria
Step Therapy Voriconazole trial/contraindication for aspergillosis Clinical documentation Coverage policy
Approval Duration Up to 6 months Approval letter Cigna policy

Frequently Asked Questions

How long does Cigna PA take for Cresemba in New Jersey? Typically 2-5 business days with complete documentation, up to 24 hours for expedited urgent cases.

What if Cresemba is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification for medical necessity.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and NJ external reviews offer expedited pathways for urgent medical situations.

Does step therapy apply if I failed voriconazole outside New Jersey? Yes, document prior therapy attempts regardless of where they occurred - Cigna recognizes out-of-state treatment history.

What happens if my appeal is denied? You can proceed to New Jersey's external review program (IHCAP) within 180 days of the final internal denial.

How do I know if my doctor submitted the PA correctly? Ask for a confirmation number and tracking information. You can also check status through Cigna's member portal.

Getting Additional Help

If you need assistance navigating the approval process, several resources are available:

  • Cigna Customer Service: Check your member ID card for the customer service number
  • NJ Department of Banking and Insurance: 1-800-446-7467 for consumer assistance
  • IHCAP Hotline: 1-888-393-1062 for external review questions
  • Counterforce Health: Professional appeal assistance for complex denials

Sources & Further Reading

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 medical circumstances. Always consult with your healthcare provider and insurance plan directly for coverage determinations. For official New Jersey insurance regulations and consumer rights, visit the NJ Department of Banking and Insurance.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.