By Counterforce Health Team in Exondys 51 (eteplirsen) —

How to Get Exondys 51 (Eteplirsen) Covered by Cigna in New Jersey: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Exondys 51 Covered by Cigna in New Jersey

To get Exondys 51 (eteplirsen) approved by Cigna in New Jersey, you need genetic testing confirming a DMD mutation amenable to exon 51 skipping, specialist prescription, and proof of ambulatory status. The fastest path: 1) Complete Cigna's Exondys 51 Prior Authorization Form with all genetic/clinical documentation, 2) Fax to (855) 840-1678 or submit via Accredo portal, 3) If denied, file internal appeal within 180 days, then external review through New Jersey's IHCAP portal. Start by verifying your plan eligibility and gathering genetic test results today.

Table of Contents

  1. Verify Your Cigna Plan Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup (Accredo)
  5. Contact Directory: Member Services & Support
  6. Appeals Process: Internal to External Review
  7. Common Denial Reasons and Solutions
  8. New Jersey Consumer Protection Resources

Verify Your Cigna Plan Coverage

Before starting your Exondys 51 prior authorization request, confirm your specific Cigna plan covers specialty medications through Express Scripts or Accredo. Not all plans have identical coverage policies.

Coverage Requirements at a Glance:

Requirement Details Source
Genetic Testing DMD mutation amenable to exon 51 skipping confirmed by CLIA-certified lab Cigna Policy
Ambulatory Status Must walk at least 180 meters in 6-minute walk test Cigna Policy
Specialist Prescription Neurologist, neuromuscular specialist, or MDA clinic Cigna Policy
Prior Authorization Required for all Cigna plans Cigna PA Form
Age Limitations No explicit age limit in current policy Cigna Policy
Note: Self-funded employer plans may have different criteria. Check your Summary Plan Description or call member services to confirm coverage details.

Required Forms and Documentation

Primary Prior Authorization Form

The Cigna Exondys 51 Prior Authorization Form must be completed in full. This form requires:

Patient Information Section:

  • Full name, date of birth, Cigna member ID
  • Diagnosis with ICD-10 code (G71.01 for DMD)
  • Current ambulatory status documentation

Clinical Documentation Required:

  • Genetic testing results showing exon 51 skipping mutation
  • 6-minute walk test results (baseline and current)
  • Prior therapy history and outcomes
  • Specialist consultation notes

Prescriber Requirements:

  • DEA number and NPI
  • Specialty credentials (neurology/neuromuscular)
  • Clinical rationale for therapy

Supporting Documents Checklist

✓ Genetic Test Report: CLIA-certified lab confirmation of DMD mutation amenable to exon 51 skipping
✓ Functional Assessment: 6-minute walk test results
✓ Specialist Notes: Initial consultation and ongoing progress notes
✓ Prior Therapy Documentation: History of corticosteroid use or other DMD treatments
✓ Insurance Card: Front and back copies
✓ Prescription: Detailed with dosing (30 mg/kg weekly IV)

Submission Portals and Methods

Electronic Submission Options

Accredo Specialty Pharmacy Portal

  • Website: Accredo.com
  • Platforms accepted: CoverMyMeds, ExpressPAth, MyAccredoPatients, Surescripts
  • Timeline: Standard review within 72 hours; urgent within 24-72 hours

Provider Portal Access

  • Register at Accredo.com using your NPI and practice information
  • Upload all required documentation directly
  • Track approval status in real-time

Fax Submission

Primary Fax Number: (855) 840-1678
Cover Sheet Must Include:

  • Patient name and Cigna member ID
  • Prescriber name and contact information
  • "URGENT" notation if expedited review needed
  • Complete document list
Tip: Always call (800) 882-4462 to confirm fax receipt within 24 hours of submission.

Specialty Pharmacy Setup (Accredo)

Once Cigna approves your prior authorization, Exondys 51 will be dispensed through Accredo, Cigna's preferred specialty pharmacy.

Step-by-Step Enrollment Process

  1. Patient Registration
    • Call Accredo at 1-866-759-1557
    • Provide Cigna member ID and prescription information
    • Complete insurance verification
  2. Clinical Intake
    • Nursing assessment for infusion site preferences
    • Schedule baseline labs if required
    • Coordinate with infusion center or home health provider
  3. Delivery Coordination
    • First shipment typically within 3-5 business days of approval
    • Temperature-controlled packaging required
    • Patient/caregiver training on handling and storage
  4. Ongoing Management
    • Monthly refill coordination
    • Adherence monitoring and support
    • Insurance renewal assistance

Patient Portal Access

Create your account at Accredo.com to:

  • Track prescription status and shipments
  • Message your care team
  • Access copay assistance programs
  • Request prescription transfers from other pharmacies

Contact Directory: Member Services & Support

Cigna Member Services

Phone: 1-800-244-6224 (24/7/365)
TTY: 711
Purpose: Coverage verification, benefits explanation, claims status

Cigna Provider Services

Phone: 1-800-88CIGNA (882-4462)
Purpose: Prior authorization status, credentialing, provider directory updates

Accredo Specialty Pharmacy

Phone: 1-866-759-1557
Purpose: Prescription enrollment, delivery scheduling, clinical support

Case Management for Rare Diseases

Access: Call main member services (1-800-244-6224) and request connection to rare disease case management
Purpose: Care coordination, treatment planning, resource navigation

Pro Tip: When calling member services, have your Cigna ID card, prescription details, and any denial letters ready to expedite assistance.

Appeals Process: Internal to External Review

Internal Appeals with Cigna

Timeline: Must file within 180 days of initial denial
Levels: Two internal review levels available
Submission: Through member portal, fax, or mail

Required Documentation for Appeal:

  • Original denial letter
  • Updated clinical notes supporting medical necessity
  • Peer-reviewed literature supporting exon 51 skipping therapy
  • Specialist letter addressing specific denial reasons

External Review Through New Jersey IHCAP

If Cigna denies your internal appeals, New Jersey's Independent Health Care Appeals Program (IHCAP) provides an independent medical review.

Eligibility Requirements:

  • Completed Cigna's internal appeal process
  • Denial based on medical necessity determination
  • Fully-insured New Jersey plan (not self-funded ERISA plans)

Submission Process:

  1. Register: Create account at njihcap.maximus.com
  2. File Appeal: Submit within 180 days of final Cigna denial
  3. Documentation: Upload all medical records, denial letters, and clinical rationale
  4. Review: Independent physician panel reviews case within 45 days

IHCAP Contact Information:

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

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient genetic testing Submit comprehensive genetic report from CLIA-certified lab Complete genetic analysis showing exon 51 skipping mutation
Non-specialist prescriber Obtain consultation from neurologist or MDA clinic Specialist consultation notes and prescription
Lack of functional assessment Provide current ambulatory status testing 6-minute walk test results with baseline comparison
Step therapy requirements Document prior corticosteroid use or contraindications Treatment history with outcomes and tolerability
Quantity or dosing limits Justify weight-based dosing per FDA labeling Patient weight, BSA calculation, and dosing rationale

Medical Necessity Letter Template Elements

When appealing, your specialist should include:

Clinical Rationale Section:

  • Confirmed DMD diagnosis with genetic testing results
  • Current functional status and disease progression
  • Prior treatment history and outcomes
  • Specific exon 51 skipping indication

Evidence-Based Support:

  • FDA approval basis for Exondys 51
  • Published clinical trial data (PROMOVI study)
  • Professional society guidelines supporting antisense therapy
  • Comparison to alternative treatments

Treatment Plan:

  • Dosing schedule (30 mg/kg weekly IV)
  • Monitoring parameters
  • Expected clinical outcomes
  • Long-term treatment goals

New Jersey Consumer Protection Resources

State Insurance Department Support

New Jersey Department of Banking and Insurance (DOBI)

  • Consumer Hotline: 1-800-446-7467
  • Website: nj.gov/dobi
  • Services: Insurance complaint filing, appeals guidance, consumer education

Additional Advocacy Resources

Patient Advocate Foundation

  • Phone: 1-800-532-5274
  • Services: Insurance appeals assistance, copay relief programs

Muscular Dystrophy Association

  • Phone: 1-833-275-6321
  • Services: Clinical care coordination, insurance navigation, family support

For complex appeals or suspected insurance violations, contact:

  • New Jersey Legal Aid: 1-888-576-5529
  • Disability Rights New Jersey: 1-800-922-7233

Frequently Asked Questions

How long does Cigna prior authorization take for Exondys 51 in New Jersey?
Standard review takes 72 hours through Accredo. Urgent requests may be processed within 24-48 hours if clinical urgency is documented.

What if Exondys 51 is non-formulary on my Cigna plan?
File a formulary exception request using the same prior authorization form. Include clinical rationale for why formulary alternatives are inappropriate.

Can I request an expedited appeal if Cigna denies coverage?
Yes, if delaying treatment would seriously jeopardize your health. Submit expedited appeal documentation to both Cigna and IHCAP if needed.

Does step therapy apply to Exondys 51 in New Jersey?
Cigna may require documentation of corticosteroid use or contraindications. New Jersey doesn't have specific step therapy protections for rare diseases like some states.

What copay assistance is available for Exondys 51?
Sarepta Therapeutics offers patient assistance programs. Contact Accredo at enrollment to apply for manufacturer copay support and foundation grants.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft compelling rebuttals that align with each payer's specific requirements, improving approval rates for critical medications like Exondys 51.

For additional support with your Cigna appeal, Counterforce Health provides specialized assistance in developing medical necessity arguments and managing the appeals process for rare disease treatments.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider. Insurance policies and state regulations may change; always verify current requirements with your insurer and state regulators. Consult with qualified healthcare professionals for medical decisions regarding Exondys 51 treatment.

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