By Counterforce Health Team in Gilenya (fingolimod) —

How to Get Gilenya (Fingolimod) Covered by Cigna in New Jersey: Forms, Appeals & Step-by-Step Guide

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

Cigna requires prior authorization for Gilenya (fingolimod) in New Jersey. Your neurologist must submit a Cigna PA form documenting your relapsing MS diagnosis, baseline EKG and eye exam, and any failed prior therapies. Submit via CoverMyMeds, your EHR, or fax to 1-866-873-8279. Standard review takes 5 business days. If denied, you have 180 days to appeal internally, then can request external review through New Jersey's Independent Health Care Appeals Program (IHCAP).

Table of Contents

Plan Types & Network Requirements

Cigna offers HMO, PPO, and EPO plans in New Jersey, each with different network rules that affect your Gilenya coverage:

Plan Type Referral Required Out-of-Network Coverage Specialty Pharmacy Network
HMO Yes (from PCP) Emergency only In-network mandatory
PPO No Yes (higher cost) Preferred network
EPO No Emergency only In-network mandatory

For HMO and EPO plans, you must use Cigna's designated specialty pharmacy network (typically Accredo) for Gilenya. PPO plans offer more flexibility but charge higher copays for out-of-network pharmacies.

Tip: Verify your plan type by checking your insurance card or logging into myCigna.com. This determines whether you need a referral from your primary care doctor to see a neurologist.

Formulary Status & Tier Placement

Gilenya is typically placed on Tier 4 or Tier 5 (specialty tier) in Cigna formularies, meaning higher out-of-pocket costs and prior authorization requirements. Cigna's 2024 formularies show fingolimod requires PA across most plans.

Step therapy may apply, requiring you to try preferred alternatives first:

  • Preferred first-line options: Dimethyl fumarate (Tecfidera), teriflunomide (Aubagio)
  • Injectable alternatives: Interferon products, glatiramer acetate
  • Infusion therapies: Ocrelizumab (Ocrevus), natalizumab (Tysabri)

Your neurologist can request a step therapy exception if these alternatives are inappropriate due to contraindications, previous failures, or intolerance.

Prior Authorization Requirements

Cigna requires comprehensive documentation for Gilenya approval:

Medical Requirements

  • Diagnosis: Relapsing forms of multiple sclerosis (documented with MRI/clinical evidence)
  • Prescriber: Neurologist or MS specialist (or consultation documented)
  • Baseline testing completed:
    • EKG before first dose and 6-hour post-dose monitoring plan
    • Ophthalmologic exam (fundus/macula screening)
    • Complete blood count, liver function tests
    • Vaccination status (live vaccines contraindicated)

Clinical Documentation

Your neurologist must provide:

  • ICD-10 diagnosis codes for MS
  • Prior therapy history and reasons for discontinuation
  • Contraindications to preferred alternatives
  • Treatment goals and monitoring plan
Note: Cigna's PA policy requires first-dose cardiac monitoring documentation before approval.

Step-by-Step: Fastest Path to Approval

1. Complete Baseline Testing (Patient + Clinic)

  • Schedule EKG and comprehensive eye exam
  • Obtain lab work (CBC, LFTs, VZV antibodies)
  • Timeline: 1-2 weeks
  • Source: FDA prescribing information

2. Neurologist Submits PA (Clinic)

3. Cigna Review Process

  • Standard review: 5 business days
  • Expedited review available for urgent cases (call 1-800-882-4462)
  • Timeline: 5 business days standard, 72 hours expedited

4. If Approved: Specialty Pharmacy Setup

  • Cigna forwards prescription to Accredo
  • Accredo contacts you within 24-48 hours
  • Timeline: 3-7 days for first shipment

5. If Denied: Immediate Appeal Prep

  • Request detailed denial reason from Cigna
  • Gather additional clinical documentation
  • Timeline: Start within 7 days of denial notice

Specialty Pharmacy Setup

Cigna routes Gilenya through Accredo specialty pharmacy. Here's what to expect:

Enrollment Process

  1. Prescription transfer: Your doctor sends the prescription directly to Accredo
  2. Patient contact: Accredo calls within 24-48 hours to verify information
  3. Insurance verification: Accredo confirms coverage and copay amounts
  4. Delivery scheduling: Coordinate shipping to your preferred address

Services Included

  • 24/7 access to specialty pharmacists and nurses
  • First-dose monitoring coordination with local healthcare facilities
  • Copay assistance program enrollment
  • Refill reminders and adherence support

Contact Accredo directly at 877-826-7657 for enrollment questions or to check prescription status.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Missing cardiac monitoring Submit EKG results and monitoring plan Pre-dose EKG, 6-hour monitoring protocol
No eye exam Complete ophthalmologic evaluation Fundus exam report, macular assessment
Step therapy not met Request exception with clinical justification Prior therapy failures, contraindications
Non-specialist prescriber Obtain neurology consultation Consultation notes, specialist recommendation
Insufficient diagnosis documentation Provide comprehensive MS workup MRI reports, clinical criteria, ICD-10 codes

Appeals Process in New Jersey

New Jersey offers robust appeal rights through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals (Required First)

  1. First-level appeal: Submit within 180 days of denial
  2. Second-level appeal: If first appeal denied
  3. Timeline: 30 days for standard, 72 hours for expedited
  4. Submit to: Cigna appeals department (contact via member services)

External Review (IHCAP)

After completing internal appeals:

  1. Eligibility: Medical necessity denials for NJ-regulated plans
  2. Timeline: 180 days from final internal denial to apply
  3. Process: Maximus Federal Services conducts independent medical review
  4. Cost: Free to members (insurer pays all costs)
  5. Decision timeline: 45 days for standard, expedited available
Important: IHCAP decisions are binding on insurers. If overturned, Cigna must provide coverage.

Contact IHCAP directly at 1-888-393-1062 for questions about the external review process.

Cost-Saving Options

Gilenya's brand-name cash price often exceeds $10,000 monthly, but several assistance options exist:

Manufacturer Support

  • Novartis Patient Assistance Program: Income-based free drug program
  • Gilenya Co-pay Program: Reduces monthly costs for commercially insured patients
  • Eligibility: Varies by program; Medicare/Medicaid restrictions apply

Generic Options

Multiple generic fingolimod formulations are now available at significantly lower costs than brand Gilenya.

Foundation Assistance

  • National MS Society: Emergency financial assistance
  • Patient Access Network Foundation: MS-specific grants
  • HealthWell Foundation: Copay assistance for qualifying patients

Accredo will screen for all available assistance programs during your enrollment call.

FAQ

How long does Cigna prior authorization take for Gilenya in New Jersey? Standard review takes 5 business days. Expedited review (for urgent medical situations) takes 72 hours. Submit complete documentation to avoid delays.

What if Gilenya is non-formulary on my Cigna plan? Request a formulary exception with clinical justification from your neurologist. Document medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and IHCAP external reviews offer expedited pathways when delays could seriously jeopardize your health.

Does step therapy apply if I failed treatments outside New Jersey? Yes, prior therapy failures from any location count toward step therapy requirements. Provide documentation from your previous neurologist.

What happens if IHCAP overturns Cigna's denial? Cigna must provide coverage as directed. The decision is legally binding under New Jersey law (N.J.S.A. 26:2S-11).

From Our Advocates

We've seen many Gilenya appeals succeed when patients and providers work together to document the complete clinical picture. One common winning strategy involves submitting both the cardiac monitoring plan and detailed notes about why first-line therapies failed or caused intolerable side effects. The key is painting a clear picture of medical necessity that addresses each specific denial reason.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance denials by creating targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling appropriate citations and clinical documentation to strengthen approval chances. Learn more at CounterforceHealth.org.

When facing a Gilenya denial from Cigna, having the right documentation and appeal strategy makes all the difference. New Jersey's strong consumer protections, including IHCAP, provide additional pathways to coverage when initial requests are denied.

Sources & Further Reading

This article provides educational information about insurance coverage and is not medical advice. Always consult your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations. For assistance with insurance appeals in New Jersey, contact the Department of Banking and Insurance or consider working with advocacy services like Counterforce Health.

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