By Counterforce Health Team in Krystexxa (pegloticase) —

How to Get Krystexxa (pegloticase) Covered by Cigna in New Jersey: Complete Authorization Guide

Answer Box: Getting Krystexxa (pegloticase) Covered by Cigna in New Jersey

Eligibility: Adults with chronic refractory gout who've failed allopurinol and febuxostat at maximum tolerated doses, with documented G6PD testing and serum uric acid ≥6 mg/dL despite treatment.

Fastest path: Submit Cigna's prior authorization form with complete treatment history, G6PD results, and a rheumatologist's letter of medical necessity. Most approvals come within 72 hours if documentation is complete.

Start today: Call Cigna at the provider services number on your insurance card to confirm whether Krystexxa is covered under medical or pharmacy benefits, then request the current PA form and submission method.

Table of Contents

  1. Patient Profile: Who Qualifies for Krystexxa Coverage
  2. Pre-Authorization Preparation
  3. Submitting Your Request
  4. Initial Outcome: Approval or Denial
  5. The Appeal Process
  6. New Jersey External Review Rights
  7. Common Denial Reasons & Solutions
  8. Cost Considerations
  9. FAQ

Patient Profile: Who Qualifies for Krystexxa Coverage

Krystexxa (pegloticase) is a specialized IV infusion therapy for adults with chronic gout that hasn't responded to standard treatments. At roughly $30,000 per infusion, it's one of the most expensive gout medications, which is why Cigna requires strict documentation before approval.

Core eligibility criteria include:

  • Diagnosis of chronic refractory gout (not just high uric acid levels)
  • Failed trials of both allopurinol and febuxostat at maximum tolerated doses
  • Serum uric acid consistently above 6 mg/dL despite treatment
  • Presence of tophi, frequent flares, or joint damage
  • Normal G6PD enzyme levels (required safety test)
  • Prescription from a rheumatologist
Note: Krystexxa is not approved for asymptomatic hyperuricemia (high uric acid without gout symptoms).

Pre-Authorization Preparation

Before submitting your request, gather comprehensive documentation. Cigna's review process focuses heavily on proving that standard gout treatments have truly failed.

Essential Documentation Checklist

Lab Results:

  • G6PD test results (within 90 days)
  • Multiple serum uric acid levels showing persistent elevation ≥6 mg/dL
  • Kidney function tests (creatinine, BUN)
  • Complete blood count

Treatment History:

  • Allopurinol trial details (dose, duration, outcome/side effects)
  • Febuxostat trial details (dose, duration, outcome/side effects)
  • Any uricosuric trials (probenecid, if attempted)
  • Documentation of maximum tolerated doses

Clinical Evidence:

  • Rheumatology consultation notes
  • Photos or descriptions of tophi
  • Flare frequency documentation
  • Joint imaging if available
  • Functional impact assessment

Letter of Medical Necessity

Your rheumatologist should prepare a detailed letter addressing Cigna's specific criteria. Counterforce Health specializes in creating evidence-backed appeals that align with each payer's requirements, turning insurance denials into targeted rebuttals with the right clinical documentation and guideline citations.

Key elements to include:

  • ICD-10 codes for chronic gout
  • Detailed description of refractory disease
  • Complete prior treatment timeline with specific doses and durations
  • Current serum uric acid levels with dates
  • Commitment to proper monitoring (uric acid before each infusion)
  • Plan for methotrexate co-therapy (unless contraindicated)

Submitting Your Request

Cigna typically processes Krystexxa requests through Express Scripts, their pharmacy benefit manager, with specialty fulfillment through Accredo.

Submission Steps

  1. Confirm benefit structure: Call Cigna to verify if Krystexxa is covered under medical or pharmacy benefits for your specific plan
  2. Obtain current forms: Request the most recent prior authorization form
  3. Complete documentation: Fill out all required fields completely
  4. Submit via preferred method: Most providers use electronic prior authorization (ePA) through Express Scripts or Accredo portals
  5. Follow up: Track submission status and respond promptly to any requests for additional information

Standard review timeline: 72 hours for routine requests, 24 hours for expedited reviews when health is at serious risk.

Initial Outcome: Approval or Denial

If Approved

Your approval letter will specify:

  • Authorized quantity and frequency (typically 8mg every 2 weeks)
  • Duration of authorization (often 6 months initially)
  • Required monitoring parameters
  • Approved infusion sites

If Denied

Don't panic. Cigna has a higher-than-average denial rate for specialty medications, but many denials are overturned on appeal when proper documentation is provided.

Common denial reasons include:

  • Insufficient documentation of prior treatment failures
  • Missing G6PD test results
  • Lack of rheumatologist prescription
  • Incomplete serum uric acid monitoring history

The Appeal Process

Cigna provides multiple levels of internal appeals before you can request external review.

Internal Appeals Process

Level 1 - Standard Appeal:

  • Deadline: 60 days from denial notice
  • Timeline: Decision within 30 days
  • Who can file: Patient, authorized representative, or prescriber

Level 2 - Second Internal Appeal:

  • Deadline: 60 days from Level 1 denial
  • Timeline: Decision within 30 days
  • Review: Different medical reviewer than Level 1

Expedited Appeals:

  • Available when delay could seriously jeopardize health
  • Decision within 72 hours
  • Can be requested at any level

Building a Strong Appeal

Your appeal should directly address each reason cited in the denial letter. Include:

  1. Point-by-point rebuttal of denial reasons
  2. Additional clinical evidence not in original submission
  3. Peer-reviewed literature supporting Krystexxa use
  4. Updated clinical notes showing disease progression
  5. Specialist letter reinforcing medical necessity

Counterforce Health can help create targeted appeals that weave together the right evidence with payer-specific workflows, significantly improving approval chances.

New Jersey External Review Rights

If Cigna upholds their denial through internal appeals, New Jersey residents have excellent external review rights through the Independent Health Care Appeals Program (IHCAP).

How IHCAP Works

New Jersey contracts with Maximus Federal Services to provide independent medical reviews. This isn't just another insurance company review – it's conducted by physician specialists in the relevant field.

Key advantages:

  • Independent reviewers: Physicians not employed by your insurance company
  • Binding decisions: If approved, Cigna must cover the treatment
  • No cost to you: Cigna pays all review fees
  • Quick timeline: 45 days for standard review, expedited options available

Filing an External Appeal

Eligibility requirements:

  • Completed Cigna's internal appeal process
  • Denial based on medical necessity or experimental/investigational classification
  • Fully insured New Jersey plan (not self-funded employer plans)
  • Filed within 4 months of final internal denial

How to file:

  1. Submit request directly to Maximus (not the NJ Department of Banking and Insurance)
  2. Include all medical records and denial letters
  3. Have your rheumatologist submit supporting documentation
  4. Request expedited review if delay poses serious health risks

Contact information:

  • IHCAP Hotline: 1-888-393-1062
  • NJ Department of Banking and Insurance Consumer Hotline: 1-800-446-7467

Common Denial Reasons & Solutions

Denial Reason Solution
"Insufficient prior treatment" Provide detailed records of allopurinol and febuxostat trials with specific doses, durations, and outcomes
"Missing G6PD testing" Submit recent G6PD test results (required safety screening)
"Not prescribed by specialist" Ensure prescription comes from rheumatologist
"Serum uric acid not documented" Include multiple uric acid levels showing persistent elevation ≥6 mg/dL
"No methotrexate co-therapy plan" Address MTX use or provide medical contraindications
"Step therapy not completed" Document trials of both allopurinol AND febuxostat at maximum tolerated doses

Cost Considerations

Even with insurance approval, Krystexxa can involve significant out-of-pocket costs.

Financial Assistance Options

Manufacturer Support:

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Various arthritis and rare disease foundations

State Programs:

  • New Jersey pharmaceutical assistance programs for qualifying residents

FAQ

Q: How long does Cigna's prior authorization process take in New Jersey? A: Standard reviews take up to 72 hours once complete documentation is received. Expedited reviews for urgent cases are completed within 24 hours.

Q: What if Krystexxa isn't on Cigna's formulary? A: You can request a formulary exception through Cigna's standard process, which follows the same prior authorization pathway with additional justification for why preferred alternatives aren't appropriate.

Q: Can I get an expedited appeal if I'm having frequent gout flares? A: Yes, if your rheumatologist documents that delay would pose serious health risks, including risk of permanent joint damage or severe functional impairment.

Q: Does New Jersey step therapy apply if I tried medications in another state? A: Yes, properly documented treatment trials from other states count toward step therapy requirements. Ensure you have complete medical records transferred.

Q: What happens if Cigna approves Krystexxa but my infusion center isn't in-network? A: You can request a network adequacy exception if no in-network providers can safely administer Krystexxa infusions in your area.

Q: How often do New Jersey external appeals succeed for specialty drugs? A: While specific statistics for Krystexxa aren't published, external reviews nationwide favor consumers in approximately 50% of cases when proper medical evidence is presented.

From Our Advocates

We've seen many Krystexxa cases initially denied for "incomplete step therapy documentation" get approved on appeal once we helped gather detailed pharmacy records showing maximum-dose allopurinol and febuxostat trials. The key is often in the specifics – exact doses, duration, and documented clinical outcomes rather than just listing medication names.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttals aligned to each plan's specific requirements. The platform identifies denial reasons and drafts point-by-point responses with the right clinical facts and guideline citations, significantly improving approval rates for complex specialty medications like Krystexxa.

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 company for guidance specific to your situation. Coverage policies and requirements may change; verify current information with official sources.

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