By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah (tisagenlecleucel) Covered by Cigna in New Jersey: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Kymriah Covered by Cigna in New Jersey

Kymriah requires prior authorization through Cigna's LifeSOURCE transplant program, not standard pharmacy benefits. For New Jersey residents, you have strong protections under state law including step therapy exceptions (effective 2026) and external appeals through IHCAP. First step today: Have your CAR-T center contact Cigna LifeSOURCE to initiate a case and submit prior authorization with complete clinical documentation showing FDA-labeled indication, prior therapy failures, and treatment at a certified center.

Table of Contents

  1. Why New Jersey State Rules Matter
  2. Prior Authorization Standards and Timelines
  3. Step Therapy Protections Under A1825
  4. Continuity of Care for CAR-T Patients
  5. External Review Through IHCAP
  6. Practical Scripts and Sample Language
  7. ERISA Plan Limitations
  8. Quick Reference Contacts
  9. FAQ

Why New Jersey State Rules Matter

New Jersey has some of the strongest patient protection laws in the country, and they directly impact how Cigna must handle your Kymriah request. Unlike many states, New Jersey requires specific timelines for prior authorization decisions and provides multiple avenues for appeals when coverage is denied.

Key New Jersey advantages:

  • Standardized step therapy exceptions starting January 1, 2026 under Assembly Bill A1825
  • 180-day prior authorization validity for chronic conditions under 2025 reforms
  • IHCAP external review with binding decisions administered by Maximus Federal Services
  • Oncology continuity of care protections up to one year if your CAR-T center leaves network

These protections apply to fully insured Cigna plans regulated by the New Jersey Department of Banking and Insurance (DOBI), including individual market plans, small and large group plans, and state employee plans.

Prior Authorization Standards and Timelines

Cigna handles Kymriah through its LifeSOURCE transplant and cellular therapy program, not through standard Express Scripts pharmacy benefits. This means your request follows medical benefit pathways with specialized case management.

Coverage at a Glance

Requirement Details Timeline Source
Prior Authorization Required through LifeSOURCE Varies by urgency Cigna LifeSOURCE Guide
FDA Indication B-cell ALL (≤25 years) or DLBCL/FL adults N/A FDA Label
Certified Center FACT-accredited CAR-T facility required N/A Plan Policy
Step Therapy May require documentation of prior failures Exception available NJ A1825
Internal Appeals Must complete before external review 180 days to file IHCAP Process

New Jersey 2025 Prior Authorization Reforms

Effective January 1, 2025, New Jersey tightened prior authorization requirements for state-regulated plans:

  • Shorter decision deadlines for carriers reviewing ordered treatments
  • 180-day validity period for approved prior authorizations involving chronic conditions
  • Enhanced appeal rights when deadlines are missed

For Kymriah patients with relapsed/refractory blood cancers, these reforms mean once your prior authorization is approved, it should remain valid for the full treatment episode including follow-up care.

Step Therapy Protections Under A1825

New Jersey's step therapy reform law (A1825), effective January 1, 2026, provides powerful tools to override "fail first" requirements that might delay CAR-T access. The law applies to NJ FamilyCare (Medicaid), State Health Benefits Program, and School Employees' Health Benefits Program.

Medical Exception Criteria

Your oncologist can request a step therapy exception if any of these apply:

  1. Contraindication/Risk of Harm: Required step therapy drug would cause adverse reactions or physical/mental harm
  2. Expected Ineffectiveness: Required drug expected to be less effective based on patient's clinical characteristics
  3. Previous Trial and Failure: Patient previously tried required drug or same class with poor results
  4. Not in Patient's Best Interest: Delay would lead to irreversible harm or rapid disease progression
  5. Stable on Current Therapy: Patient already stable on provider-selected treatment

Exception Process Timeline

  • Urgent requests: 24-hour decision required
  • Non-urgent requests: 72-hour decision required
  • Duration: When granted, exception valid for 180 days or full course of therapy
Tip: For CAR-T cases, emphasize rapid disease progression and the narrow window for CAR-T eligibility to qualify for urgent review.

Continuity of Care for CAR-T Patients

If your CAR-T center loses Cigna network status during your treatment, New Jersey provides strong continuity protections:

State Protections (N.J.A.C. 11:24B-5.3(f))

  • Oncologic treatment: Up to 1 year of continued in-network treatment after provider termination
  • General ongoing care: Up to 4 months for medically necessary continuing treatment
  • Exceptions: No protection if termination for fraud, breach, or imminent danger

Federal Protections (No Surprises Act)

  • 90-day transitional period for "continuing care patients" with serious/complex conditions
  • Same cost-sharing as before termination
  • Provider must accept plan payment plus in-network cost sharing as payment in full

To invoke these protections, immediately request "continuity of care" or "transitional care" in writing from Cigna, citing both New Jersey regulations and federal law.

External Review Through IHCAP

When Cigna denies your Kymriah request and internal appeals fail, New Jersey's Independent Health Care Appeals Program (IHCAP) provides an independent medical review with binding authority.

IHCAP Eligibility for CAR-T

You can file an IHCAP appeal if:

  • Your plan is New Jersey-regulated (not self-funded ERISA)
  • Denial was based on medical necessity or experimental/investigational status
  • You completed internal appeals or couldn't reasonably complete them
  • You file within 4 months of final internal denial

Process and Timeline

Filing Options:

  • Online: Register at njihcap.maximus.com
  • Fax: Submit to Maximus NJ IHCAP (verify current fax number)
  • Mail: Maximus Federal - NJ IHCAP, Pittsford, NY

Decision Timeline:

  • Preliminary review: 5 business days to confirm eligibility
  • Standard appeal: 45 calendar days for final decision
  • Expedited appeal: 48 hours for urgent cases

Key Documents to Include:

  • Original denial letter and all internal appeal decisions
  • Signed consent form for medical record release
  • Detailed physician letter explaining medical necessity
  • Supporting literature (FDA label, NCCN guidelines, peer-reviewed studies)
  • Complete treatment history showing prior therapy failures
Note: IHCAP decisions are binding on both the insurer and patient. Carriers often reverse denials during the review process to avoid an official loss.

Practical Scripts and Sample Language

Internal Appeal Letter Template

When appealing a Kymriah denial to Cigna, include this language adapted to your specific situation:

Re: Appeal of Denial for Kymriah (tisagenlecleucel) - [Member Name, DOB, ID]

I am appealing the denial dated [date] for chimeric antigen receptor T-cell (CAR-T) therapy, Kymriah (tisagenlecleucel), to treat [diagnosis].

Medical Necessity and Guideline Support
Kymriah is FDA-approved for this indication and recommended in NCCN guidelines for patients who have failed prior therapies comparable to this case. The member has undergone and failed [number] prior regimens including [list key treatments].

Compliance with New Jersey Law
For New Jersey-regulated health plans, this denial must comply with the External Treatment and Patient Appeal Act (ETPAA), N.J.S.A. 17B:30-55.2(g), and 2025 prior authorization reforms requiring 180-day validity for chronic condition approvals.

Step Therapy Exception (if applicable)
If this denial involves step therapy requirements, I request an exception under New Jersey Assembly Bill A1825, which requires rapid review (24-72 hours) and allows exceptions when additional therapy delay is not in the patient's best interest.

Requested Action: Please authorize Kymriah at [FACT-accredited center] as medically necessary and guideline-supported treatment.

Phone Script for Cigna

When calling Cigna about your Kymriah case:

"I'm calling about prior authorization for Kymriah CAR-T therapy. This should be routed through your LifeSOURCE transplant program, not standard pharmacy benefits. I need to speak with someone who handles CAR-T cases and can access my LifeSOURCE file. My member ID is [ID] and the request was submitted by [CAR-T center name]."

ERISA Plan Limitations

Important limitation: If you have a self-funded employer plan (most large employers), New Jersey state protections may not apply. Self-funded ERISA plans are governed by federal law and typically use federal external review processes rather than IHCAP.

How to check your plan type:

  • Ask your HR department if the plan is "fully insured" or "self-funded"
  • Look for "insured by Cigna" vs. "administered by Cigna" language
  • Self-funded plans often have different member ID formats

Even with ERISA plans, you still have federal appeal rights and may benefit from similar strategies using federal rather than state law citations.

Quick Reference Contacts

New Jersey Resources

  • DOBI Consumer Hotline: 1-800-446-7467
  • IHCAP Hotline: 1-888-393-1062
  • IHCAP Online Portal: njihcap.maximus.com

Cigna Resources

  • Member Services: Number on your ID card
  • LifeSOURCE: Contact through your CAR-T center
  • Provider Portal: CignaforHCP.com (for providers)

Patient Advocacy

  • American Cancer Society: Cancer-related insurance assistance
  • Patient Advocate Foundation: General coverage appeals support

Counterforce Health: Expert Coverage Appeals

When facing complex CAR-T denials, specialized expertise can make the difference between approval and continued delays. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft targeted, evidence-backed rebuttals.

The platform pulls appropriate citations from FDA labeling, peer-reviewed studies, and specialty guidelines, then weaves them into appeals that align with each plan's specific requirements. For CAR-T cases like Kymriah, this includes addressing payer-specific criteria around CD19 positivity, certified treatment centers, and prior therapy documentation while meeting all procedural requirements for coverage determinations and appeals.

FAQ

How long does Cigna prior authorization take for Kymriah in New Jersey?
Timeline varies by case complexity and urgency. Standard requests may take 5-15 business days through LifeSOURCE, while urgent cases can be expedited. New Jersey's 2025 reforms require shorter decision deadlines for state-regulated plans.

What if Kymriah is non-formulary on my Cigna plan?
CAR-T therapies are typically covered under medical benefits, not pharmacy formularies. Even if not listed on your drug formulary, Kymriah may still be covered through Cigna's transplant/cellular therapy benefit with prior authorization.

Can I request an expedited appeal in New Jersey?
Yes. Both Cigna's internal process and New Jersey's IHCAP offer expedited reviews for urgent cases. For CAR-T, emphasize that delay risks disease progression and loss of treatment eligibility.

Does step therapy apply if I failed treatments outside New Jersey?
Treatment history from other states should count toward step therapy requirements. Document all prior therapies with medical records, regardless of where treatment occurred.

What's the success rate for CAR-T appeals in New Jersey?
While specific CAR-T success rates aren't published, Counterforce Health reports that well-documented appeals citing FDA approval and guidelines often succeed, especially when payers initially deny as "experimental" despite regulatory approval.

How do I know if my Cigna plan is regulated by New Jersey?
Fully insured individual and group plans purchased in New Jersey are typically state-regulated. Self-funded employer plans (common with large employers) follow federal rules. Check with HR or look for "insured by" vs. "administered by" language in plan documents.

What happens if Cigna misses New Jersey appeal deadlines?
Under New Jersey law, carriers that miss required deadlines may face penalties and automatic approval requirements. Document all submission dates and follow up promptly when deadlines pass.

Can my CAR-T center help with the appeal process?
Yes. Most certified CAR-T centers have financial counselors and patient advocates experienced with insurance appeals. They can often provide stronger clinical documentation and may file appeals on your behalf with proper consent.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical situation. For personalized guidance, consult with your healthcare team and insurance representatives.

Sources & Further Reading:

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