By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by Cigna in North Carolina: Complete PA Guide with Appeals Process

Answer Box: Getting Kesimpta Covered by Cigna in North Carolina

Fastest path to approval: Verify Kesimpta requires prior authorization through your Cigna plan, have your neurologist submit the Multiple Sclerosis CCRD Prior Authorization Form via CoverMyMeds or Surescripts ePA, and designate Accredo Specialty Pharmacy for dispensing. If denied, file internal appeal within 180 days, then request external review through Smart NC within 120 days. First step today: Call the number on your Cigna ID card to verify PA requirements and formulary status.

Table of Contents

  1. Start Here: Verify Your Plan and Requirements
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Electronic Options
  4. Specialty Pharmacy Setup with Accredo
  5. Appeals Process: Cigna Internal to Smart NC External
  6. Support Phone Numbers and Contacts
  7. Common Denial Reasons and Solutions
  8. Costs and Financial Assistance
  9. FAQ: Kesimpta Coverage in North Carolina

Start Here: Verify Your Plan and Requirements

Before starting the prior authorization process, confirm these key details about your Cigna coverage:

Coverage Verification Checklist

What to verify:

  • Is Kesimpta (ofatumumab) on your specific formulary?
  • What tier is it classified under (typically specialty tier)?
  • Does it require prior authorization (PA)?
  • Is step therapy required?
  • Must you use Accredo Specialty Pharmacy?

How to check:

  1. Log into myCigna portal and use the "Price a Medication" tool
  2. Call the member services number on your ID card
  3. Review your Cigna formulary document (verify with current year version)
Note: Kesimpta is typically classified as a specialty medication requiring prior authorization and dispensing through Accredo Specialty Pharmacy for most Cigna plans.

Prior Authorization Forms and Requirements

The Cigna MS Prior Authorization Form

Cigna uses a specific "Multiple Sclerosis CCRD Prior Authorization Form" that explicitly lists Kesimpta among covered MS agents. This form includes:

  • Standard vs. urgent review options
  • Site-of-care selection (Accredo is listed as "Cigna's nationally preferred specialty pharmacy")
  • Clinical questions about MS diagnosis and disease activity
  • Prior therapy documentation requirements

Download the form: Cigna MS PA Form (PDF)

Required Clinical Documentation

Your neurologist must provide:

Essential Information:

  • MS diagnosis with ICD-10 code (G35 for multiple sclerosis)
  • Disease course classification (relapsing-remitting, clinically isolated syndrome, active secondary progressive)
  • Prior MS therapies tried, including dates and outcomes
  • Reason for selecting Kesimpta over formulary alternatives
  • Current disease activity status

Supporting Documents:

  • Recent MRI reports showing lesion activity
  • Documentation of prior treatment failures or intolerances
  • Laboratory results (complete blood count, liver function tests)
  • Hepatitis B screening results
  • Vaccination status verification

Submission Portals and Electronic Options

Electronic Prior Authorization (Preferred Method)

Primary submission channels:

  1. CoverMyMeds: Access through Cigna's PA portal
  2. Surescripts ePA: Submit directly through your provider's EHR system
  3. eviCore (Evernorth): For some Cigna programs, access through the Cigna precertification page

Manual Submission Options

If electronic submission isn't available:

  • Fax: Use the fax number provided on the MS PA form
  • Phone: Call Cigna Pharmacy Management for urgent requests
Tip: Electronic submissions typically process faster and allow direct upload of supporting medical records.

Specialty Pharmacy Setup with Accredo

Why Accredo is Required

Most Cigna plans require specialty medications like Kesimpta to be dispensed through Accredo Specialty Pharmacy for coverage. The MS PA form specifically designates Accredo as the preferred option.

Setting Up with Accredo

For patients:

  1. Call Accredo Patient Services: 1-800-803-2523
  2. Provide your Cigna insurance information
  3. Request assignment to the MS Therapeutic Resource Center
  4. Schedule injection training if needed

For prescribers:

  1. E-prescribe to Accredo (1620 Century Center Pkwy, Memphis, TN 38134-8822)
  2. Call Accredo Physician Service Center: 844-516-3319 for coordination
  3. Provide clinical documentation to support the PA request

Appeals Process: Cigna Internal to Smart NC External

Cigna Internal Appeal Process

Timeline: File within 180 days of denial notice

How to file:

  1. Use the Cigna Customer Appeal Request form
  2. Include the original denial letter
  3. Attach comprehensive medical necessity documentation
  4. Submit via member portal, mail, or fax

Review timeframes:

  • Standard: 30 days for pre-service decisions
  • Expedited: 72 hours for urgent requests

North Carolina External Review (Smart NC)

If Cigna's internal appeal is denied, North Carolina residents can request an external review through Smart NC.

Eligibility requirements:

  • State-regulated Cigna plan (not self-funded employer plans)
  • Completed Cigna's internal appeal process
  • Denial based on medical necessity or experimental/investigational determination

How to request external review:

  1. Call Smart NC: 1-855-408-1212 within 120 days of final internal denial
  2. Complete the external review request form
  3. Submit supporting medical records and denial letters

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (24-72 hours for urgent drug denials)
Important: The Independent Review Organization's decision is binding on Cigna. If overturned, Cigna must provide coverage within 3 business days.

Support Phone Numbers and Contacts

For Patients

Cigna Member Services: Number on your ID card Accredo Patient Services: 1-800-803-2523 Smart NC Consumer Help: 1-855-408-1212 Cigna Specialty Condition Counseling: 1-800-633-4227

For Healthcare Providers

Accredo Physician Service Center: 844-516-3319 Cigna Specialty Pharmacy Services: 1-800-351-3606 Cigna Precertification: 1-800-882-4462

Case Management Support

Cigna Pathwell Specialty Care Manager: 1-877-505-3681 (Mon-Fri, 8 AM-7 PM ET)

Common Denial Reasons and Solutions

Denial Reason How to Address Required Documentation
Step therapy not completed Document prior MS therapies and failures Treatment history with dates, outcomes, and adverse events
Insufficient medical necessity Provide clinical rationale and guidelines Specialist letter citing MS treatment guidelines and disease activity
Missing safety labs Complete required screening Hepatitis B panel, CBC, liver function tests
Overlapping DMT therapy Confirm washout period Documentation of previous therapy discontinuation
Non-formulary status File formulary exception request Medical necessity letter explaining why formulary alternatives are inappropriate

Costs and Financial Assistance

Manufacturer Support Programs

Novartis Patient Assistance:

Additional Resources

  • Patient Advocate Foundation: Financial assistance for specialty medications
  • North Carolina prescription assistance programs: Contact Smart NC for state-specific options

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, pulling the right clinical evidence and citations to support medical necessity arguments.

FAQ: Kesimpta Coverage in North Carolina

How long does Cigna prior authorization take for Kesimpta in North Carolina? Standard PA decisions are made within 72 hours of receiving a completed request. Urgent requests are processed within 24 hours. If Cigna doesn't respond within these timeframes, the request is considered approved.

What if Kesimpta is not on my Cigna formulary? You can request a formulary exception through the same MS PA form process. Your neurologist must demonstrate that formulary alternatives are clinically inappropriate or have failed.

Can I request an expedited appeal if my Kesimpta is denied? Yes, if delay would seriously jeopardize your health or ability to regain function. Mark the appeal as "urgent" and have your doctor document the clinical urgency.

Does step therapy apply if I've tried MS medications outside North Carolina? Yes, treatment history from other states is accepted. Provide documentation of prior therapies, dates, and outcomes regardless of where treatment occurred.

What happens if Smart NC external review overturns Cigna's denial? The decision is binding on Cigna. They must provide coverage for Kesimpta within 3 business days of the external review decision.

How do I transfer my Kesimpta prescription to Accredo? Call Accredo Patient Services at 1-800-803-2523 with your prescription information and Cigna member details. They'll coordinate the transfer and PA process with your neurologist.

Can I appeal a quantity limit on my Kesimpta prescription? Yes, quantity limit appeals follow the same process as PA denials. Your doctor must justify the prescribed quantity based on clinical need and FDA labeling.

What if my employer plan is self-funded - can I still use Smart NC? Self-funded ERISA plans are generally not eligible for North Carolina external review unless the employer has specifically opted in. Contact Smart NC at 1-855-408-1212 to verify eligibility.

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage varies by plan. Always verify current requirements with your specific Cigna plan and consult healthcare providers for medical decisions.

Sources & Further Reading:

For personalized assistance with Kesimpta appeals and prior authorization challenges, Counterforce Health provides comprehensive support to help patients access their prescribed medications through targeted, evidence-based appeal strategies.

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