By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by Cigna in Michigan: Forms, Appeals, and Approval Scripts

Answer Box: Getting Kesimpta Covered by Cigna in Michigan

Kesimpta (ofatumumab) is on Cigna's formulary but requires prior authorization and may need step therapy. To get approved: 1) Have your neurologist submit a PA request with MS diagnosis, prior therapy failures, and clinical notes to Cigna/Express Scripts, 2) Use Accredo Specialty Pharmacy for fulfillment (877-826-7657), 3) If denied, file an internal appeal within 180 days, then request Michigan DIFS external review within 127 days. Most approvals happen within 60 days when documentation is complete.

Table of Contents

Plan Types & Network Requirements

Your Cigna plan type affects how you access Kesimpta and specialists in Michigan:

HMO Plans: Require referrals from your primary care physician to see neurologists. You must stay in-network and use designated specialty pharmacies. Monthly premiums range from $2,823-$3,819 for individuals in Michigan.

PPO Plans: No referrals needed for specialists, and you can see out-of-network providers (though costs are higher). More pharmacy flexibility but higher premiums around $1,834 for individuals.

EPO Plans: No referrals required, but you must stay in-network except for emergencies. Pricing falls between HMO and PPO options.

Tip: For multiple sclerosis care requiring frequent specialist visits and specialty medications, PPO plans often provide the most flexibility despite higher costs.

Formulary Status & Coverage

Kesimpta is included on Cigna's 2024 Medicare and commercial formularies but comes with restrictions:

  • Prior authorization required for all plans
  • Step therapy may apply depending on your specific formulary
  • Specialty tier placement means higher cost-sharing
  • Quantity limits may restrict monthly supplies

The drug is approved for relapsing forms of multiple sclerosis in adults, including clinically isolated syndrome (CIS), relapsing-remitting MS, and active secondary progressive MS.

Prior Authorization Requirements

Cigna's clinical criteria for Kesimpta are specific and must be documented thoroughly:

Initial Authorization Criteria

  • Confirmed relapsing MS diagnosis with medical records
  • Neurologist or MS specialist prescribing or consulting
  • Documentation of insufficient response, intolerance, or contraindication to other standard MS therapies (dimethyl fumarate, interferon-beta, glatiramer acetate)
  • Objective confirmation via MRI, relapse history, or progression measures

Renewal Criteria (≥1 year on therapy)

  • Clinical benefit demonstration using objective measures:
    • Stabilized or decreased MRI progression
    • Reduced relapse frequency/severity
    • No evidence of disease progression per standardized scales
  • Continued specialist care coordination

Specialty Pharmacy Setup

Cigna requires Kesimpta to be filled through Accredo Specialty Pharmacy for coverage:

Contact Accredo: 877-826-7657 (Mon-Fri 7 AM-10 PM CST, Sat 7 AM-4 PM CST)

Setup Process:

  1. Your doctor sends the prescription electronically to Accredo
  2. Call Accredo to verify benefits and coordinate delivery
  3. Register for myCigna.com to track shipments and refills
  4. Accredo provides home delivery statewide in Michigan, including refrigerated medications

Services Included:

  • 24/7 access to specialty-trained pharmacists
  • Injection training and side effect management
  • Copay assistance program coordination

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

  • Insurance card and policy details
  • Complete MS diagnosis records with ICD-10 codes
  • MRI reports showing lesion activity
  • Documentation of previous MS therapies tried and failed
  • Current neurological exam findings

2. Complete Prior Authorization Form (Prescriber)

3. Set Up Accredo Account (Patient)

  • Call 877-826-7657 immediately after PA submission
  • Verify insurance benefits and copay
  • Schedule delivery and injection training
  • Timeline: Same-day setup possible

4. Monitor PA Status (Patient/Clinic)

  • Check myCigna portal for updates
  • Follow up if no response within 30 days
  • Request expedited review if clinically urgent

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient prior therapy trials Document specific medications tried, dates, and reasons for discontinuation Pharmacy records, clinic notes showing intolerance/failure
Missing specialist involvement Get neurologist consultation or referral Letter from MS specialist supporting treatment
Incomplete clinical documentation Submit comprehensive medical records MRI reports, EDSS scores, relapse history
Step therapy not completed Request medical exception or complete required steps Clinical justification for bypassing preferred alternatives

Appeals Process in Michigan

Internal Appeals (Cigna)

  • Deadline: 180 days from denial notice
  • Timeline: Decision within 60 days
  • Expedited option: 24 hours for urgent drug needs
  • Submit to: Cigna appeals department via member portal or mail

External Review (Michigan DIFS)

If internal appeal fails:

Note: Michigan's 127-day external review deadline is longer than the federal 120-day standard, giving you extra time to gather documentation.

Cost Considerations

Insurance Coverage: Kesimpta is a specialty biologic with high costs. Your out-of-pocket expenses depend on your plan's specialty tier copay or coinsurance.

Manufacturer Support: Novartis offers patient assistance programs for eligible patients, including:

  • Copay assistance for commercially insured patients
  • Free drug programs for uninsured/underinsured patients
  • Foundation grants through independent organizations

State Resources: Michigan residents may qualify for additional prescription assistance through state programs or nonprofit foundations.

When to Escalate

Contact Michigan regulators if you experience:

  • Unreasonable delays beyond stated timelines
  • Repeated denials without clear clinical rationale
  • Procedural violations in the appeals process

Michigan DIFS: 877-999-6442 for insurance complaints and external review requests

Clinician Corner: Medical Necessity Documentation

When submitting PA requests, include these key elements:

Clinical Rationale Checklist:

  • Specific MS phenotype (RRMS, CIS, active SPMS)
  • Objective disease activity (MRI lesions, relapses)
  • Prior DMT trials with dates and outcomes
  • Contraindications to preferred alternatives
  • Treatment goals and monitoring plan

Supporting Evidence: Reference FDA labeling, AAN/ECTRIMS guidelines, and peer-reviewed literature supporting ofatumumab use in your patient's specific situation.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. Their platform helps clinicians save time on PA submissions while improving approval rates through payer-specific workflows and comprehensive documentation strategies.

FAQ

Q: How long does Cigna prior authorization take for Kesimpta in Michigan? A: Standard review takes up to 60 days, but most decisions come within 2-4 weeks when documentation is complete. Expedited review is available within 24 hours for urgent cases.

Q: What if Kesimpta isn't on my specific Cigna formulary? A: You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why preferred alternatives aren't appropriate.

Q: Can I use a local specialty pharmacy instead of Accredo? A: Cigna typically requires Accredo for specialty medications. Using other pharmacies may result in no coverage or higher costs.

Q: Does step therapy apply if I've already failed other MS drugs? A: Document all prior therapies with dates and reasons for discontinuation. This evidence can support bypassing step therapy requirements.

Q: What happens if my appeal is denied in Michigan? A: You can request external review through Michigan DIFS within 127 days. Their independent medical experts make binding coverage decisions.

Q: Can I get expedited appeals for MS medications? A: Yes, if your doctor certifies that delays would seriously jeopardize your health or if you're in ongoing treatment requiring continuity.

From Our Advocates

We've seen successful Kesimpta appeals when families work closely with their MS specialist to document not just the diagnosis, but the specific pattern of disease activity and why other treatments haven't worked. The key is painting a clear clinical picture that aligns with Cigna's written criteria—when the medical story matches their policy requirements, approvals often follow quickly.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with your specific plan. For personalized assistance with complex denials, platforms like Counterforce Health can help transform your clinical documentation into targeted appeals that address payer-specific requirements and improve your chances of approval.

Sources & Further Reading

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