By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

How to Get Acthar Gel Covered by Cigna in New Jersey: Complete Guide to Prior Authorization, Appeals, and Forms

Answer Box: Getting Acthar Gel Covered by Cigna in New Jersey

Acthar Gel requires prior authorization from Cigna in New Jersey. Your fastest path to approval: Have your neurologist call Cigna Pharmacy Services at (800) 882-4462 with clinical documentation showing failed corticosteroid therapy or contraindications. Submit the PA request via CoverMyMeds or fax with complete medical records. If denied, you have 180 days to appeal internally, then can request an external review through New Jersey's IHCAP program administered by Maximus. Start the process 2-3 weeks before you need the medication.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Enrollment (Accredo)
  5. Support Lines and Case Management
  6. Appeals Process: Internal and External
  7. New Jersey External Review Rights (IHCAP)
  8. Common Denial Reasons and Solutions
  9. Resources and Updates

Verify Your Plan and Find the Right Forms

Before starting your Acthar Gel prior authorization, confirm you have a fully-insured Cigna plan (not self-funded employer coverage, which follows different rules). Check your member ID card or call Cigna member services at the number on your card.

Coverage at a Glance: Acthar Gel with Cigna

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all Cigna plans PA form needed before coverage Cigna PA Policy
Formulary Status Specialty tier, high cost-share Check your plan's drug list Cigna Formulary
Step Therapy Required (try corticosteroids first) Must document failure/contraindication PA Criteria
Age Restrictions Under 2 for infantile spasms Specific criteria by indication Coverage Policy
Specialty Pharmacy Accredo required Enrollment needed Accredo Info

Prior Authorization Forms and Requirements

Cigna requires specific clinical documentation for Acthar Gel approval. The requirements vary by indication:

For Infantile Spasms

  • Child under 24 months
  • EEG showing hypsarrhythmia
  • Prescribed by neurologist
  • Used as monotherapy
  • Initial approval: 1 month

For MS Exacerbations

  • Adult patient (18+)
  • Acute exacerbation diagnosis
  • Prescribed by neurologist or MS specialist
  • Documentation of methylprednisolone failure or contraindication
  • Initial approval: 1 month

Required Documentation:

  • Complete diagnosis with ICD-10 codes
  • Prior corticosteroid trials and outcomes
  • Current clinical status and treatment goals
  • Dose and duration per FDA labeling
  • Relevant lab results or imaging
Clinician Corner: Your medical necessity letter should address Cigna's specific denial reasons. Include peer-reviewed evidence supporting Acthar Gel over standard corticosteroids for the patient's condition, document contraindications to alternatives, and reference FDA labeling or specialty guidelines.

Submission Portals and Methods

Fastest Submission Methods:

  1. CoverMyMeds Portal (Recommended)
    • Online at covermymeds.com
    • Integrated with most EHR systems
    • Real-time status updates
    • Upload supporting documents directly
  2. SureScripts via EHR
    • Submit directly from electronic health record
    • Automatic form population
    • Fastest processing time
  3. Fax Submission
    • Use current PA form from Cigna Forms Portal
    • Include cover sheet with patient info
    • Fax number provided on form (verify current number)

Processing Timeline: Standard requests take 5 business days. Urgent requests can be expedited by calling (800) 882-4462.

Specialty Pharmacy Enrollment (Accredo)

Acthar Gel must be dispensed through Cigna's specialty pharmacy, Accredo. Start enrollment 2-3 weeks before your first dose.

Step-by-Step Enrollment:

  1. Call Accredo: (877) 826-7657
    • Hours: Monday-Friday 7 AM-10 PM CST, Saturday 7 AM-4 PM CST
    • Have your prescription and insurance info ready
  2. Provider Referral: Your doctor submits prescription via Accredo referral forms
  3. Patient Portal Setup: Access through myCigna app once enrolled
  4. Delivery Coordination: Accredo ships temperature-controlled medications nationwide
Tip: Accredo provides injection training, 24/7 pharmacist support, and coordination with your healthcare team. They'll also handle prior authorization follow-up if needed.

Support Lines and Case Management

Key Cigna Contact Numbers for New Jersey:

  • Cigna Pharmacy Prior Authorization: (800) 882-4462
    • Provider services and PA status
    • Expedited review requests
    • Case management support
  • Member Services: Number on your ID card
    • Coverage questions
    • Appeals assistance
    • Benefit verification

What to Ask When You Call:

  • "What's the status of PA request #[number]?"
  • "Can this be expedited due to medical urgency?"
  • "What additional documentation is needed?"
  • "Can you connect me with a case manager?"

Appeals Process: Internal and External

If Cigna denies your Acthar Gel request, you have multiple appeal options in New Jersey.

Internal Appeals Timeline:

  1. First Level Appeal: 180 days from denial
    • Submit written appeal with new clinical evidence
    • Decision within 30 days (72 hours if expedited)
  2. Second Level Appeal: Available for most plans
    • Independent medical review
    • Additional 30 days for decision

Required Appeal Documents:

  • Original denial letter
  • Updated medical necessity letter
  • New clinical evidence or guidelines
  • Peer-reviewed studies supporting use
From Our Advocates: We've seen success when appeals include specific citations from FDA labeling and specialty society guidelines. One effective approach is addressing each denial reason point-by-point with corresponding clinical evidence and explaining why alternatives aren't suitable for the patient's specific situation.

New Jersey External Review Rights (IHCAP)

New Jersey offers robust external review rights through the Independent Health Care Appeals Program (IHCAP), now administered by Maximus.

When to Use External Review:

  • Completed internal appeals process
  • Denial based on medical necessity
  • Fully-insured New Jersey plan
  • Within 4 months of final internal denial

How to File:

  1. Get Forms: External Appeal Application from your denial letter or NJ IHCAP Portal
  2. Submit Documentation:
    • Completed application
    • Denial letters from Cigna
    • Medical records
    • Provider consent forms (if applicable)
  3. Contact Information:

Timeline: Standard reviews completed within 45 days. Expedited reviews (for urgent cases) completed within 48 hours.

Important: External review decisions are binding on Cigna. If Maximus overturns the denial, Cigna must provide coverage.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide condition-specific evidence FDA label, clinical guidelines, peer-reviewed studies
"Step therapy not completed" Document corticosteroid failure/contraindication Treatment records, adverse event documentation
"Experimental/investigational" Cite FDA-approved indications FDA labeling, compendia listings
"Quantity/frequency exceeds limits" Justify dose per medical guidelines Clinical rationale, weight-based dosing calculations
"Non-formulary drug" Request formulary exception Medical necessity for Acthar vs. alternatives

Resources and Updates

Official Resources:

Patient Assistance:

  • Mallinckrodt Patient Support: Check manufacturer website for current programs
  • New Jersey Department of Banking and Insurance: (800) 446-7467

Update Schedule: Check Cigna's formulary and PA requirements quarterly, as policies can change. Always verify current forms and contact information before submitting requests.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed, payer-specific strategies. Our platform analyzes denial letters and creates targeted rebuttals that address each plan's specific criteria, helping streamline the complex prior authorization and appeals process for medications like Acthar Gel.

FAQ

How long does Cigna PA take for Acthar Gel in New Jersey? Standard processing is 5 business days. Expedited reviews for urgent cases can be completed within 24-72 hours when requested through (800) 882-4462.

What if Acthar Gel is non-formulary on my Cigna plan? Request a formulary exception through your physician. Provide medical necessity documentation showing why Acthar Gel is required over formulary alternatives.

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

Does step therapy apply if I failed corticosteroids outside New Jersey? Yes, document prior treatment failures regardless of where they occurred. Cigna accepts out-of-state medical records as evidence of step therapy completion.

What happens if I'm on a self-funded employer plan? Self-funded plans follow federal ERISA rules, not New Jersey insurance laws. External appeals go through federal processes, not NJ IHCAP.

How much does external review cost in New Jersey? Nothing. Insurers pay all costs for NJ IHCAP external reviews. Patients and providers pay no fees.

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 for specific guidance. For personalized assistance with complex prior authorizations and appeals, consider working with Counterforce Health to develop targeted, evidence-based strategies for your specific situation.

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