By Counterforce Health Team in Gilenya (fingolimod) —

How to Get Gilenya (Fingolimod) Covered by Cigna in Georgia: Appeals, Forms, and State Protections

Answer Box: Getting Gilenya (Fingolimod) Covered by Cigna in Georgia

Gilenya requires prior authorization from Cigna in Georgia. Your doctor must submit documentation including baseline EKG and eye exam results, plus proof of relapsing MS diagnosis. If denied, you have 180 days for internal appeals and 60 days for external review through Georgia's Department of Insurance. Start by having your neurologist complete the prior authorization request with all required monitoring documentation—this is your fastest path to approval.

First step today: Contact your prescribing neurologist to confirm they have your baseline EKG and ophthalmologic exam results ready for the PA submission.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Cigna plans Cigna formulary documents Cigna PA Policy
Baseline EKG Must be completed before first dose Provider must document in PA request Cigna PA Policy
Eye Exam Ophthalmologic evaluation required Provider must document in PA request Cigna PA Policy
Specialist Requirement Neurologist or MS specialist must prescribe Prescription must come from qualified provider Cigna PA Policy
Diagnosis Documentation Relapsing MS with ICD-10 codes Medical records must support diagnosis Cigna PA Policy

Step-by-Step: Fastest Path to Approval

1. Confirm Your Baseline Tests (Patient + Clinic)

  • EKG within past 6 months: Required due to bradycardia risk
  • Ophthalmologic exam: Must be completed before starting
  • Timeline: Schedule immediately if not done
  • Submit via: Include results in PA request

2. Gather Prior Treatment History (Clinic)

  • Document previous MS therapies: Include drug names, duration, outcomes
  • Note failures or intolerances: Specific reasons for discontinuation
  • Timeline: Compile within 1-2 business days
  • Submit via: Cigna Provider Portal or fax 1-866-873-8279

3. Complete Prior Authorization Request (Clinic)

  • Required forms: Cigna PA request with clinical justification
  • Include: Diagnosis codes, baseline test results, treatment history
  • Timeline: Submit within 72 hours of gathering documentation
  • Track: Request confirmation number

4. Follow Up on Decision (Patient + Clinic)

  • Standard timeline: 72 hours for most determinations
  • Expedited: 24 hours if urgent medical need
  • Check status: Via provider portal or member services
  • Document: Save all communications

Georgia State Protections That Help

Step Therapy Override Rights

Georgia law (Code §33-24-59.25) requires insurers to grant step therapy exceptions when:

  • Previous drug failures: You've tried and failed required medications
  • Contraindications exist: Required drugs would cause harm
  • Current stability: You're doing well on current therapy
  • Expected ineffectiveness: Required drug unlikely to work for your condition

Timeline for decisions: 24 hours for urgent requests, 2 business days for standard requests.

Continuity of Care Protection

If you're switching insurance plans in Georgia, you have rights to up to 60 days of continued coverage for chronic conditions like MS. This applies when:

  • Moving from one Cigna plan to another
  • Changing from another insurer to Cigna
  • Your employer changes insurance carriers

Action required: Request continuity of care immediately after enrollment in the new plan.

Appeals Playbook for Cigna in Georgia

Internal Appeals (First Level)

Timeline: 180 days from denial date How to file:

  • Online via Cigna member portal
  • Mail to address on denial letter
  • Fax: (verify current number with customer service)

Required documents:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Supporting clinical documentation
  • Prior treatment records

External Review (After Internal Appeals)

Timeline: 60 days from final internal denial How to file: Georgia Department of Insurance

  • Phone: 1-800-656-2298
  • Email: [email protected]
  • Process: DOI assigns independent medical review

Cost: Free to consumers Decision timeline: 30 business days (72 hours if urgent) Binding: Yes, insurers must comply with favorable decisions

From our advocates: We've seen many Georgia patients successfully overturn Gilenya denials by submitting comprehensive medical necessity letters that specifically address the baseline monitoring requirements. The key is demonstrating that all safety protocols are in place and that alternative treatments haven't been effective.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing baseline EKG Submit EKG results showing normal cardiac function Recent EKG report with interpretation
No eye exam documented Provide ophthalmologic evaluation Complete eye exam with macular assessment
Insufficient prior trials Document step therapy failures or contraindications Treatment history with specific outcomes
Not medically necessary Submit detailed medical necessity letter Clinical rationale with guideline citations
Quantity limits exceeded Justify dosing based on clinical need Provider attestation of appropriate dosing

When Your Plan Type Matters

Cigna Medicare Advantage

  • Coverage: Follows Medicare Part D rules and Cigna formulary
  • Appeals: Medicare appeals process applies
  • Timeline: Standard Medicare deadlines
  • External review: Through Medicare, not Georgia DOI

Commercial Fully-Insured Plans

  • Coverage: Subject to Georgia insurance laws
  • Appeals: Internal appeals plus Georgia external review
  • Timeline: Georgia deadlines apply
  • Protections: Full Georgia consumer protections

ERISA Self-Funded Plans

  • Coverage: Employer determines benefits
  • Appeals: Federal ERISA rules only
  • Timeline: Plan document governs
  • Protections: Limited state law protections

Counterforce Health helps patients navigate these complex coverage differences by analyzing denial letters and crafting targeted appeals that address the specific requirements of each plan type.

Scripts for Calling Cigna

For Prior Authorization Status

"Hi, I'm calling to check the status of a prior authorization request for Gilenya (fingolimod) submitted by [doctor's name] on [date]. My member ID is [number]. Can you tell me if any additional documentation is needed?"

For Step Therapy Exception

"I need to request a step therapy exception for Gilenya under Georgia Code 33-24-59.25. My previous MS medications [list drugs] were ineffective/caused adverse reactions. My doctor has documentation supporting this exception request."

For Appeal Assistance

"I received a denial for Gilenya and want to file an internal appeal. Can you confirm the deadline and required forms? I also want to understand my rights under Georgia law for external review if needed."

Cost-Saving Options

Manufacturer Support

  • Novartis patient assistance: Income-based free drug program
  • Copay savings card: Up to $25,000 annual assistance for eligible patients
  • Eligibility: Check Novartis patient support (verify current programs)

Foundation Grants

  • National MS Society: Drug assistance programs
  • Patient Access Network: MS-specific grants
  • Good Days: Chronic disease assistance

Generic Options

Multiple fingolimod generics now available with significantly lower cash prices than brand Gilenya.

FAQ

How long does Cigna prior authorization take in Georgia? Standard requests: 72 hours. Expedited requests: 24 hours. Timeline starts when all required documentation is received.

What if Gilenya isn't on my Cigna formulary? Request a formulary exception with medical necessity justification. Include documentation of why formulary alternatives aren't appropriate.

Can I get expedited appeals in Georgia? Yes, for urgent medical situations. Both Cigna internal appeals and Georgia external review offer expedited timelines when delay poses health risks.

Do I need to try other MS drugs first? Depends on your specific plan's step therapy requirements. Georgia law allows exceptions if previous drugs failed or are contraindicated.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna. External appeals in Georgia are reviewed by independent medical experts assigned by the state Department of Insurance.

How do I prove medical necessity for Gilenya? Your neurologist should document: MS diagnosis with ICD-10 codes, previous treatment failures, contraindications to alternatives, and clinical rationale for Gilenya specifically.

When navigating complex prior authorization requirements, services like Counterforce Health can help by analyzing your specific denial and crafting evidence-based appeals that address Cigna's exact coverage criteria.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance requirements with your specific plan. For personalized assistance with insurance appeals, contact the Georgia Department of Insurance Consumer Services Division at 1-800-656-2298.

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