By Counterforce Health Team in Filsuvez (birch triterpenes topical gel) —

How to Get Filsuvez (Birch Triterpenes Gel) Covered by Cigna in New York: Complete Cost & Appeals Guide 2025

Answer Box: Getting Filsuvez Covered by Cigna in New York

Filsuvez (birch triterpenes gel) requires prior authorization from Cigna and isn't on standard formularies. Three-step path: (1) Your doctor submits a PA with EB diagnosis confirmation and prior therapy documentation to Cigna at 1-800-882-4462, (2) If denied, file internal appeal within 180 days, (3) Request New York external review within 4 months through DFS ($25 fee, often waived). Commercial insurance patients may qualify for $0 copay through Chiesi Total Care (833-670-6464). Start today by asking your prescriber to initiate the prior authorization process.

Table of Contents

What Drives Filsuvez Costs with Cigna

Understanding your benefit design helps predict out-of-pocket costs for Filsuvez, which retails around $27,000-$28,000 per treatment pack according to GoodRx pricing data.

Coverage Tier Impact Filsuvez isn't listed on Cigna's standard 2024-2025 formularies but requires prior authorization as a specialty drug. When covered, it typically falls under the highest specialty tier with 25-33% coinsurance or fixed copays ranging $1,000-$3,000+ per fill until you reach your plan's out-of-pocket maximum.

Key Cost Factors:

  • Deductible: Must be met before coinsurance kicks in
  • Specialty tier: Highest cost-sharing level on most plans
  • Out-of-pocket maximum: Annual limit after which Cigna covers 100%
  • Quantity limits: May restrict tubes per month, affecting total annual cost
Note: New York residents have strong appeal rights if coverage is denied, including binding external review through the Department of Financial Services.

Benefit Investigation: What to Ask

Before starting treatment, gather specific benefit details from Cigna customer service (member ID number on your insurance card).

Essential Questions for Cigna:

  1. "Is Filsuvez on my plan's formulary, and what tier?"
  2. "What's my specialty drug deductible and coinsurance percentage?"
  3. "Does my plan require step therapy or quantity limits for topical EB treatments?"
  4. "Which specialty pharmacy must I use - Accredo or Express Scripts?"
  5. "What's my annual out-of-pocket maximum for prescription drugs?"

Information to Record:

  • Plan type (HMO, PPO, Medicare Advantage)
  • Specialty pharmacy network requirements
  • Prior authorization criteria specific to your plan
  • Appeal deadlines and process
  • Customer service reference number

Call Cigna at the number on your member ID card, and ask to speak with someone knowledgeable about specialty drug benefits.

Assistance Options: Copay Cards and Grants

Multiple programs can dramatically reduce your Filsuvez costs, especially if you have commercial insurance.

Chiesi Total Care Copay Assistance Eligible patients with commercial insurance may pay as little as $0 per prescription through the manufacturer's program.

Eligibility Requirements:

  • Must have private/commercial insurance (not Medicare, Medicaid, TRICARE)
  • U.S. resident (some state exclusions apply)
  • Age 18+ (or parent/guardian enrollment for minors)
  • Valid FDA-approved prescription

How to Apply: Call 833-670-6464 (Mon-Fri, 8am-8pm ET) or download the enrollment form and fax to 877-914-0591. Annual renewal required by December 31.

Foundation Grants for All Insurance Types The Assistance Fund's EB Program, in partnership with debra of America, covers:

  • Prescription copays and deductibles
  • Health insurance premiums
  • Travel costs for treatment
  • Genetic testing expenses

Apply at (833) 570-2833 or through their online portal. No annual cap on support duration once enrolled.

debra of America Direct Aid Based in New York, this national nonprofit provides:

  • Free wound care supplies (bandages, dressings, ointments)
  • Legal advocacy for insurance denials
  • Mini-grants through the Smile Fund
  • Contact: (212) 868-1573

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Filsuvez. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned to your plan's specific coverage policies.

Getting Coverage When Filsuvez Isn't on Formulary

Since Filsuvez isn't routinely listed on Cigna formularies, you'll need either prior authorization approval or a formulary exception.

Medical Necessity Documentation Your prescriber must submit comprehensive clinical justification including:

  • Confirmed diagnosis of junctional or dystrophic EB (genetic testing results preferred)
  • Documentation of wound characteristics (size, duration, location)
  • Prior therapy failures or contraindications
  • Treatment goals and monitoring plan
  • FDA labeling support for the specific EB subtype

Cigna's PA Submission Methods:

  • Electronic: Through CoverMyMeds or Cigna provider portal
  • Phone: 1-800-882-4462
  • Fax: 1-866-873-8279

Expedited Review Request urgent processing if wound infection risk or other medical urgency exists. Cigna must respond within 72 hours for expedited requests.

Clinician Corner: Include ICD-10 codes (Q81.1 for junctional EB, Q81.2 for dystrophic EB), prior treatment documentation, and cite FDA approval for wounds in EB patients ≥6 months old in your medical necessity letter.

Specialty Pharmacy Coordination

Cigna typically routes Filsuvez through Accredo or Express Scripts specialty pharmacies, which provide additional support services.

Accredo Services:

  • Prior authorization coordination
  • Insurance benefit verification
  • Clinical support and monitoring
  • Home delivery with temperature control

Express Scripts Integration:

  • Electronic PA submission through provider portals
  • Member tracking via Express Scripts app
  • Coordination with Cigna benefits

Coordination Tips:

  1. Confirm which specialty pharmacy your plan requires
  2. Ensure your prescriber has the correct pharmacy contact information
  3. Ask about patient assistance program enrollment during intake
  4. Request delivery tracking and temperature monitoring confirmation

The specialty pharmacy will typically contact you within 24-48 hours of receiving the prescription to verify benefits and coordinate delivery.

Appeals Process in New York

New York residents have robust appeal rights, including access to binding external review for coverage denials.

Internal Appeals with Cigna

Timeline: File within 180 days of denial Response Time: 30 days standard, 72 hours expedited How to File: Written appeal through member portal, mail, or fax

Required Documentation:

  • Original denial letter
  • Prescriber's medical necessity letter
  • Clinical notes and test results
  • Any new supporting evidence

New York External Appeal Process

If Cigna upholds the denial after internal appeal, you can request external review through the New York State Department of Financial Services.

Key Details:

  • Deadline: 4 months from final internal denial
  • Fee: $25 (waived for Medicaid/financial hardship)
  • Timeline: 30 days standard, 72 hours expedited
  • Decision: Binding on both patient and insurer

How to File: Submit application to DFS with all denial letters and medical documentation. Use the official NY External Appeal Application form available at dfs.ny.gov.

Success Tips:

  • Include specialist letters emphasizing unmet medical need
  • Cite FDA approval and clinical guidelines
  • Document risks of treatment delay
  • Highlight failed alternative therapies
From Our Advocates: We've seen EB cases succeed on external appeal when families included detailed photos showing wound progression, genetic test results confirming the specific EB subtype, and letters from wound care specialists explaining why standard dressings were insufficient. The key is demonstrating medical necessity specific to the patient's condition.

Annual Planning and Renewals

Plan ahead for formulary changes and benefit resets that occur each January 1st.

Annual Checklist:

  • Review new formulary documents (available October-November)
  • Confirm specialty pharmacy network changes
  • Renew manufacturer copay assistance programs
  • Update income documentation for foundation grants
  • Check for new prior authorization requirements

What Can Change:

  • Formulary tier placement
  • Copay/coinsurance amounts
  • Step therapy requirements
  • Quantity limits
  • Preferred specialty pharmacy

Budgeting Strategy: If Filsuvez moves to a higher tier or faces new restrictions, file a formulary exception request before January 1st to ensure continuous coverage.

Conversation Scripts

Calling Cigna Customer Service: "Hi, I need to verify benefits for Filsuvez, spelled F-I-L-S-U-V-E-Z, for epidermolysis bullosa treatment. Can you tell me if it's on my formulary, what tier it's on, and whether prior authorization is required? I also need to know my specialty drug deductible and coinsurance percentage."

Requesting Peer-to-Peer Review: "This is [clinic name] requesting a peer-to-peer review for a Filsuvez prior authorization denial. The patient has dystrophic EB with chronic wounds that haven't responded to standard care. Our dermatologist needs to speak with your medical director about the clinical necessity."

Specialty Pharmacy Follow-up: "I'm calling about my Filsuvez prescription that was sent over yesterday. Can you confirm you received it, verify my insurance benefits, and let me know the expected timeline for prior authorization and delivery?"

Counterforce Health can help draft more detailed appeal letters and coordinate with your clinical team to strengthen prior authorization requests with evidence-based arguments tailored to Cigna's specific coverage policies.

FAQ

How long does Cigna prior authorization take for Filsuvez? Standard review takes up to 15 business days, but expedited review (72 hours) is available for urgent medical needs. Request expedited processing if wound infection risk exists.

What if Filsuvez isn't on my Cigna formulary? Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate that Filsuvez is medically necessary and that formulary alternatives are inappropriate for your specific EB subtype.

Can I appeal a Cigna denial in New York? Yes. File internal appeal within 180 days, then request external review through NY DFS within 4 months of final denial. External review decisions are binding on Cigna.

Does step therapy apply to Filsuvez? Cigna may require documentation of failed standard wound care therapies, but step therapy through other prescription topicals is less common given Filsuvez's unique indication for EB.

What copay assistance is available? Commercial insurance patients may qualify for $0 copay through Chiesi Total Care. Foundation grants through The Assistance Fund and debra of America help with all insurance types.

Which specialty pharmacy will fill my prescription? Cigna typically requires Accredo or Express Scripts. Check your specific plan's specialty pharmacy network or call customer service to confirm.

Disclaimer: This information is for educational purposes only and doesn't constitute medical or legal advice. Insurance coverage varies by plan. Always verify current policies with your insurer and consult healthcare providers for medical decisions.

Need Help with Appeals? Contact Community Health Advocates at 888-614-5400 for free assistance with New York insurance appeals, or visit the NY Department of Financial Services at dfs.ny.gov for external appeal forms and guidance.

Sources & Further Reading

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