By Counterforce Health Team in Duopa (carbidopa/levodopa enteral) —

How to Get Duopa (Carbidopa/Levodopa Enteral) Covered by Cigna in New Jersey: Complete Requirements Guide and Appeals Process

Answer Box: Getting Duopa Covered by Cigna in New Jersey

Eligibility: Cigna requires prior authorization for Duopa (carbidopa/levodopa enteral) for members with advanced Parkinson's disease experiencing at least 3 hours daily of "OFF" episodes despite optimized oral therapy.

Fastest Path to Approval:

  1. Have your neurologist complete Cigna's Duopa prior authorization form with detailed clinical documentation
  2. Submit through CoverMyMeds or fax to 1-866-873-8279
  3. Ensure Accredo Specialty Pharmacy is designated as your dispensing pharmacy

First Step Today: Contact your movement disorder specialist or neurologist to begin gathering documentation of failed oral therapies and "OFF" episode frequency. Standard review takes 15 days; expedited reviews complete within 72 hours.

Table of Contents

Who Should Use This Guide

This guide is designed for Cigna members in New Jersey with advanced Parkinson's disease who need Duopa (carbidopa/levodopa enteral suspension) covered by their insurance. You should use this if you're experiencing:

  • Significant "OFF" episodes (at least 3 hours daily) despite optimized oral medications
  • Motor fluctuations that impact your quality of life
  • Intolerance or inadequate response to multiple Parkinson's medications

Expected Outcome: Following this guide increases your chances of first-time approval and helps you navigate appeals if initially denied. Counterforce Health has helped patients turn insurance denials into successful approvals by providing evidence-backed appeals that address payer-specific requirements.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage with prescription benefits
  • Prior authorization required for all Duopa prescriptions
  • Specialty pharmacy mandate: Must use Accredo (Cigna's preferred specialty pharmacy)
  • Annual reauthorization: Not required as of July 2024

Plan Types Covered

  • Commercial Cigna plans
  • Cigna Medicare Advantage (with Part B coverage)
  • Some employer-sponsored plans (verify coverage)
Note: Self-funded employer plans may have different requirements. Check your Summary of Benefits or contact Cigna member services at 1-800-244-6224.

Clinical Criteria Requirements

Primary Requirements

Requirement Details Documentation Needed
Diagnosis Advanced Parkinson's disease with motor fluctuations ICD-10: G20.A2 or G20.B2
OFF Episodes At least 3 hours daily of "OFF" time Detailed symptom diary or clinic notes
Failed Oral Therapy Inadequate response to extended-release carbidopa/levodopa Pharmacy records, dosing history
Step Therapy Failed 3+ additional Parkinson's medications Complete medication trial documentation
Specialist Care Prescription from neurologist or movement disorder specialist Current provider credentials

Specific Failed Therapies Required

Cigna requires documentation of failure, intolerance, or contraindication to:

  1. Extended-release oral carbidopa/levodopa (e.g., Rytary, Sinemet CR)
  2. Three additional agents from different classes:
    • Dopamine agonists (pramipexole, ropinirole)
    • COMT inhibitors (entacapone, tolcapone)
    • MAO-B inhibitors (rasagiline, selegiline, safinamide)
    • Other agents (opicapone, cabergoline)

Coding & Documentation Requirements

ICD-10 Codes (Effective October 2023)

  • G20.A2: Parkinson's disease without dyskinesia, with fluctuations
  • G20.B2: Parkinson's disease with dyskinesia, with fluctuations

HCPCS Code

  • J7340: Carbidopa/levodopa enteral suspension (1 unit = one 100-mL cassette)

Required Clinical Documentation

  • Recent neurology evaluation (within 6 months)
  • Detailed "OFF" episode documentation
  • Complete medication history with specific reasons for discontinuation
  • Surgical candidacy assessment for PEG-J tube placement

Documentation Packet Checklist

Provider Requirements

  • Completed Cigna Duopa prior authorization form
  • Current medical license and DEA number
  • Specialty certification (neurology/movement disorders)

Clinical Documentation

  • Comprehensive neurological evaluation (≤6 months)
  • Motor fluctuation diary or detailed symptom log
  • Complete medication trial history with outcomes
  • Assessment of surgical candidacy for PEG-J placement
  • Treatment goals and expected outcomes

Medical Necessity Letter Components

Your neurologist should include:

  1. Patient presentation: Specific symptoms and functional impact
  2. Prior treatments: Detailed list with doses, duration, and outcomes
  3. Clinical rationale: Why Duopa is medically necessary
  4. Supporting evidence: FDA labeling, clinical guidelines
  5. Monitoring plan: Follow-up schedule and safety assessments

Submission Process

Submission Methods (in order of preference)

  1. CoverMyMeds portal (fastest processing)
  2. SureScripts through EHR
  3. Fax: 1-866-873-8279
  4. Phone: 1-800-88CIGNA (1-800-882-4462)

Timeline Expectations

  • Standard review: 15 calendar days
  • Expedited review: 72 hours (for urgent cases)
  • Additional information requests: May extend timeline

Required Form Fields

Ensure all mandatory fields are completed:

  • Patient demographics and Cigna ID
  • Prescriber information and credentials
  • Clinical indication and diagnosis codes
  • Accredo Specialty Pharmacy designation
  • Detailed dosing and administration plan

Specialty Pharmacy Setup

Accredo Enrollment Process

  1. Prescriber designates Accredo on prior authorization form
  2. Patient enrollment: Call 877-826-7657 after approval
  3. Account setup: Register at accredo.com
  4. Shipping coordination: Home delivery or alternate location

Accredo Contact Information

  • Phone: 877-826-7657
  • Fax: 888-302-1028
  • Website: accredo.com
  • Mobile app: Available for prescription management

After Submission: Tracking Your Request

Confirmation Steps

  1. Record confirmation number from submission
  2. Set calendar reminders for follow-up (days 5, 10, 14)
  3. Monitor myCigna portal for status updates
  4. Prepare for additional information requests

Status Check Schedule

  • Day 3: Verify receipt of submission
  • Day 7: Check for additional information requests
  • Day 12: Follow up if no response received
  • Day 15: Escalate if decision not received

Appeals Process in New Jersey

Internal Appeals with Cigna

  1. First-level appeal: File within 180 days of denial
    • Timeline: Decision within 30 days (72 hours if expedited)
    • Submission: Online portal or fax
  2. Second-level appeal: If first appeal denied
    • Timeline: 30 days for decision
    • Review: Independent medical professional

New Jersey External Review (IHCAP)

After exhausting Cigna's internal appeals:

  1. Eligibility: 180 days from final internal denial
  2. Process: Submit directly to Maximus Federal Services
  3. Timeline: 5 business days for acceptance, 45 days for decision
  4. Cost: Free to patients (insurers pay all fees)
  5. Binding decision: Cigna must comply if overturned

New Jersey Resources

  • IHCAP Hotline: 1-888-393-1062
  • DOBI Consumer Hotline: 1-800-446-7467
  • Online appeals portal: Available through Maximus
From our advocates: We've seen cases where detailed clinical documentation of "OFF" episodes and failed medication trials led to successful appeals, even after initial denials. The key is providing specific, measurable data about functional impact and treatment history.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient "OFF" episode documentation Submit detailed symptom diary Motor fluctuation log with times/severity
Missing step therapy documentation Provide complete medication history Pharmacy records + provider notes
Lack of specialist evaluation Obtain movement disorder specialist consult Recent neurological assessment
Surgical candidacy unclear Include GI/surgical evaluation PEG-J placement assessment
Incomplete prior authorization form Resubmit with all fields completed Updated form with required signatures

Costs & Patient Support

AbbVie Patient Support

  • AbbVie Care: Financial assistance and copay support
  • Phone: 1-800-222-6885
  • Eligibility: Income-based assistance available

Additional Resources

  • Parkinson's Foundation: Patient assistance programs
  • Patient Access Network (PAN): Copay assistance
  • New Jersey pharmaceutical assistance: State programs for eligible residents

Estimated Costs

  • Wholesale cost: ~$7,000/month for medication
  • With insurance: Varies by plan (typically $50-500/month)
  • Without coverage: Full retail price applies

FAQ

How long does Cigna prior authorization take in New Jersey? Standard reviews take 15 calendar days, while expedited reviews complete within 72 hours for urgent cases.

What if Duopa is non-formulary on my Cigna plan? You can request a formulary exception through the prior authorization process, providing clinical justification for medical necessity.

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

Does step therapy apply if I failed medications outside New Jersey? Yes, medication failures from any location count toward step therapy requirements if properly documented.

What happens if my PEG-J tube needs replacement? Replacement tubes and ongoing supplies are typically covered under durable medical equipment (DME) benefits once Duopa therapy is approved.

How do I know if my Cigna plan covers Duopa? Contact Cigna member services at 1-800-244-6224 or check your formulary. Most plans cover Duopa with prior authorization.

Getting insurance coverage for specialty medications like Duopa can feel overwhelming, but you don't have to navigate this process alone. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with insurance appeals and coverage issues, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467.

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