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

How to Get Filsuvez (Birch Triterpenes Topical Gel) Covered by Cigna in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Fast Track to Filsuvez Coverage

Cigna requires prior authorization for Filsuvez (birch triterpenes topical gel) in New Jersey. Your fastest path: 1) Have your dermatologist submit a Cigna PA form with dystrophic EB diagnosis, wound photos, and cancer screening results. 2) If denied, file an internal appeal within 180 days. 3) Use New Jersey's IHCAP external review if still denied. Start today: Call the number on your Cigna card to request the current PA form for your specific plan.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Requirements
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process for New Jersey
  6. Support Contacts
  7. Common Denial Reasons & Solutions
  8. Costs & Financial Assistance
  9. FAQ

Verify Your Plan & Find the Right Forms

Before starting, confirm whether your pharmacy benefit is managed by Cigna directly or through Express Scripts. Check the back of your insurance card for pharmacy-specific contact information.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all Filsuvez prescriptions Cigna Policy IP0635
Covered Indication Dystrophic epidermolysis bullosa only FDA labeling
Age Requirement ≥6 months Policy IP0635
Prescriber Dermatologist or wound care specialist Policy IP0635
Authorization Duration 3 months initial/renewal Policy IP0635
Appeals Deadline (NJ) 180 days from denial NJ DOBI Guide
Note: Junctional EB and other subtypes are not covered under Cigna's current policy, despite FDA approval for both dystrophic and junctional forms.

Prior Authorization Requirements

Cigna's National Formulary Coverage Policy IP0635 sets specific criteria for Filsuvez approval, effective July 15, 2024.

Initial Therapy Criteria

All of the following must be met:

  1. Confirmed dystrophic EB diagnosis (genetic testing preferred)
  2. At least one open target wound suitable for treatment
  3. Cancer screening completed - squamous cell and basal cell carcinoma ruled out
  4. Specialist prescriber - dermatologist or wound care specialist experienced in EB
  5. Complete clinical documentation including wound photos and measurements

Continuation Therapy Requirements

For previously treated wounds:

  • Target wound remains open
  • Documented decrease in wound size from baseline
  • Continued specialist oversight
Clinician Corner: Your medical necessity letter should include: EB subtype confirmation (genetic test results), wound location/size in cm², duration of current wound, prior treatment failures, cancer screening results (biopsy if indicated), and treatment plan with expected duration.

Submission Portals & Methods

Cigna Provider Portal:

  • Log in at Cigna's provider portal
  • Navigate to pharmacy precertification section
  • Upload PA form and supporting documents

CoverMyMeds/Surescripts:

  • Many Cigna plans accept electronic PA through these platforms
  • Search for "Filsuvez" and select your patient's specific Cigna plan

Fax & Mail Options

Standard PA Fax: Use the fax number provided on your patient's specific Cigna PA form (varies by plan)

Expedited Reviews: If delay could harm patient health, mark "URGENT" on all submissions and call Cigna customer service to expedite.

Tip: Include a cover sheet listing: Patient name/DOB, Cigna ID number, prescriber NPI, requested drug (Filsuvez), and total pages sent.

Specialty Pharmacy Setup

Most Cigna plans require Filsuvez to be dispensed through Accredo specialty pharmacy.

Onboarding Steps

  1. Member Registration:
  2. Prescription Transfer:
    • Accredo will contact your dermatologist's office
    • Provide PA approval letter and clinical notes
    • Coordinate delivery (including temperature-controlled shipping)
  3. Patient Support Services:
    • Injection training (if applicable)
    • Copay assistance coordination
    • Refill reminders and adherence support

Counterforce Health helps patients navigate complex specialty pharmacy requirements by streamlining the prior authorization process and ensuring all necessary documentation reaches the right departments quickly.

Appeals Process for New Jersey

Internal Appeals (Required First Step)

Timeline: 180 days from denial date Contact: Use appeals address on your denial letter

Required Documents:

  • Original denial letter
  • Updated medical records
  • Prescriber's appeal letter addressing denial reasons
  • Any new clinical evidence

New Jersey External Review (IHCAP)

If Cigna upholds the denial after internal appeals, New Jersey residents can request an independent external review through the Independent Health Care Appeals Program.

Key Details:

  • Administrator: Maximus Federal Services
  • Deadline: 180 days from final internal denial
  • Cost: $25 filing fee (capped at $75/year per member)
  • Decision Timeline: 45 days standard, 48 hours expedited
  • Binding: Cigna must comply with favorable decisions within 10 business days

Expedited Fax for Urgent Cases: (585) 425-5296

From Our Advocates: We've seen cases where patients initially denied for "experimental" reasons succeeded on external review by providing comprehensive EB specialist letters explaining why standard wound care had failed and citing the FDA approval specifically for dystrophic EB. The key was demonstrating medical necessity with objective wound measurements and photos.

Support Contacts

Member Services

  • Cigna General: 1-800-244-6224 (24/7)
  • TTY/TDD: Dial 711
  • Ask for: "Case management for rare disease" or "complex condition support"

Provider Services (New Jersey)

  • QualCare-administered plans: 1-844-883-2423
  • General Cigna provider line: 1-800-882-4462
  • Request: "Care management coordination" or "prior authorization assistance"

New Jersey Consumer Assistance

  • DOBI Consumer Hotline: 1-800-446-7467
  • IHCAP-specific line: 1-888-393-1062
  • Managed Care Ombudsman: Available through NJ Dept. of Human Services

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Provide EB specialist letter with wound progression data Photos showing lack of healing, specialist notes
"Experimental/investigational" Reference FDA approval (Dec 2024) and clinical guidelines FDA label, EB foundation guidelines
"Insufficient documentation" Submit complete clinical package Genetic testing, wound measurements, treatment history
"Wrong EB subtype" Clarify dystrophic vs. junctional diagnosis Genetic panel results, dermatology consultation
"Cancer not ruled out" Provide screening results Biopsy reports, clinical exam notes

Costs & Financial Assistance

Retail Cost: Approximately $27,631 for common quantities (GoodRx pricing)

Financial Support Options

Manufacturer Assistance:

  • Contact Chiesi Global Rare Diseases patient support
  • May offer copay cards or patient assistance programs

Foundation Grants:

  • EB Research Partnership
  • Dystrophic Epidermolysis Bullosa Research Association (DEBRA)
  • National Organization for Rare Disorders (NORD)

State Programs:

  • New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD)
  • Check eligibility at NJ Department of Human Services

At Counterforce Health, we've helped families reduce out-of-pocket costs by ensuring proper prior authorization documentation prevents unnecessary delays that could trigger emergency cash payments.

FAQ

Q: How long does Cigna PA take in New Jersey? A: Standard reviews: 72 hours. Expedited reviews: 24 hours if delay could harm health.

Q: What if Filsuvez is non-formulary on my plan? A: Request a formulary exception through the same PA process, emphasizing medical necessity and lack of covered alternatives.

Q: Can I appeal if I tried step therapy drugs in another state? A: Yes. Provide documentation of prior trials and outcomes, regardless of where treatment occurred.

Q: Does New Jersey have expedited external review? A: Yes. IHCAP offers expedited review (48-hour decision) if delay would seriously jeopardize health.

Q: What if my dermatologist isn't experienced with EB? A: Consider consultation with an EB specialist. Major centers include Stanford, Cincinnati Children's, and Columbia University.

Q: Can providers file external appeals on my behalf? A: Yes. New Jersey allows providers to file IHCAP appeals with patient consent.

When to Escalate

Contact the New Jersey Department of Banking and Insurance if:

  • Cigna doesn't respond within required timeframes
  • You're told services aren't available that should be covered
  • The insurer doesn't comply with a favorable IHCAP decision

Consumer Complaint Process:

  • File online at NJ DOBI website
  • Include all denial letters, appeal correspondence, and timeline documentation
  • DOBI can investigate potential violations of state insurance laws

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and appeal processes may change; verify current requirements with Cigna and New Jersey regulatory authorities.

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