By Counterforce Health Team in Mycapssa (octreotide, oral) —

How to Get Mycapssa (Octreotide Oral) Approved by Cigna in New Jersey: Complete Forms & Appeals Guide

Answer Box: Getting Started with Cigna Coverage for Mycapssa in New Jersey

Mycapssa (oral octreotide) requires prior authorization from Cigna, processed through Express Scripts specialty pharmacy. The fastest approval path involves: (1) Your endocrinologist submitting electronic PA via CoverMyMeds with baseline IGF-1 labs and specialist documentation, (2) Setting up Accredo specialty pharmacy delivery at 877-826-7657, and (3) If denied, filing internal appeals within 180 days, then external review through New Jersey's IHCAP portal within 4 months. Standard PA processing takes 15 business days; expedited requests process in 72 hours for urgent cases.

Table of Contents

Verify Your Plan and Find Current Forms

Before starting the approval process, confirm your Cigna plan includes specialty drug coverage through Express Scripts. Log into your myCigna account to verify:

  • Specialty pharmacy benefit: Most Cigna plans route specialty drugs like Mycapssa through Accredo
  • Formulary status: Check if Mycapssa appears on your plan's drug list
  • Prior authorization requirements: Confirmed required for all Cigna commercial plans
Note: Mycapssa is FDA-approved specifically for acromegaly maintenance treatment in adults who previously responded to injectable octreotide or lanreotide. Off-label uses face higher denial rates.

Prior Authorization Forms and Requirements

Key Documentation Needed

Cigna's National Formulary policy CNF_390 requires:

  • Specialist prescription: Must be prescribed by or in consultation with an endocrinologist
  • Baseline IGF-1 levels: From a certified laboratory before starting any somatostatin analog therapy
  • Prior therapy documentation: Evidence of previous response to injectable octreotide (Sandostatin) or lanreotide (Somatuline)
  • Diagnosis confirmation: Acromegaly with appropriate ICD-10 coding

Current Forms (Updated 2024-2025)

Access the most current prior authorization forms through Cigna's prescription forms portal. Look for somatostatin analog or octreotide-specific forms.

Electronic Submission Portals

Primary Electronic Options (Fastest Processing)

  1. CoverMyMeds (Recommended)
  2. SureScripts via EHR
    • Integrated electronic submission through your doctor's electronic health record system
    • Automatic routing to appropriate Cigna department
  3. MyAccredoPatients.com
    • Prescriber portal for specialty drug PA submissions
    • Register via email link with PIN faxed by Accredo
    • Includes real-time PA status and order tracking

Fax and Mail Submission Details

National Fax Numbers

  • General specialty drug PA: (855) 840-1678
  • Medical prior authorization: (866) 873-8279
  • Urgent requests: Fax to (855) 840-1678 AND call (800) 882-4462 immediately

Cover Sheet Requirements

Include all asterisked (*) fields on forms:

  • Patient name, Cigna ID, date of birth, address
  • Physician name, DEA/NPI/TIN, contact information
  • Drug name, strength, dosing schedule, diagnosis
  • Clinical details including lab values and prior treatments
Tip: Incomplete forms cause automatic delays. Double-check all required fields before faxing.

Accredo Specialty Pharmacy Setup

Mycapssa requires specialty pharmacy dispensing through Cigna's preferred network. Here's how Counterforce Health typically guides patients through this process:

Patient Enrollment Steps

  1. Contact Accredo: Call 877-826-7657 (Mon-Fri 7am-10pm CST, Sat 7am-4pm)
  2. Provide information: Patient details, prescriber info, current therapy history
  3. Timeline: Allow 5-7 days for new/transfer orders (2-3 days processing + shipping)
  4. Delivery: Free shipping to home or doctor's office; refrigerated storage if needed

Online Account Setup

  • Log into myCigna app/website
  • Select Prescriptions > My Medications
  • Connect to Accredo account for order tracking and refills
  • Enable text refill reminders

Support Lines and Contacts

Patient Support

  • Cigna Customer Service: Number on your insurance card
  • Specialty drug questions: 1-800-882-4462
  • Accredo patient support: 877-826-7657

Provider Support

  • Prior authorization phone: 1-800-882-4462 or 1-866-494-2111 (specialty prompt)
  • Urgent PA requests: Same numbers with urgency attestation
  • MyAccredoPatients portal: Real-time PA submission and tracking

New Jersey External Review Process

If Cigna denies coverage after internal appeals, New Jersey offers free external review through the Independent Health Care Appeals Program (IHCAP).

Eligibility Requirements

  • Completed Cigna's internal appeal process (or plan waived requirement)
  • Denial based on medical necessity, experimental/investigational determination
  • Fully-insured New Jersey plan or NJ FamilyCare/Medicaid coverage
  • Filed within 4 months of final internal denial

Submission Process

Electronic (Preferred): Register at njihcap.maximus.com

Required Documents:

  • Signed External Appeal Application
  • All internal denial letters
  • Medical records release authorizations
  • Provider medical necessity letter with supporting literature

Alternative Submission:

  • Fax: (585) 425-5296
  • Mail: Maximus Federal Services, 3750 Monroe Ave, Suite 705, Pittsford, NY 14534

Timeline

Appeal Type Processing Time
Standard 5 business days acceptance notice; 45 days full review
Expedited 48 hours (for urgent cases where delay could cause harm)
Important: External review is free, and Maximus decisions are binding on insurers. Success rates are favorable when comprehensive clinical evidence is provided.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient documentation Submit comprehensive clinical records IGF-1 labs, specialist notes, imaging results
Step therapy not completed Document prior injectable SSA use Treatment history, dates, outcomes, intolerances
Not medically necessary Provide detailed necessity letter Disease progression risk, quality of life impact
Off-label use Emphasize FDA-approved acromegaly indication Diagnosis confirmation, appropriate ICD-10 codes

Appeals Timeline and Process

Internal Appeals with Cigna

  • Filing deadline: 180 days from denial (commercial plans)
  • Standard review: 30-60 days
  • Expedited review: 72 hours for urgent cases
  • Submission address: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422

External Review (New Jersey IHCAP)

  • Filing deadline: 4 months from final internal denial
  • Cost: Free to patients
  • Decision timeline: 45 days standard, 48 hours expedited
  • Binding: Yes, insurers must comply with favorable decisions

When patients face complex denials, Counterforce Health helps draft targeted, evidence-backed appeals that address specific payer policies and denial rationales.

Costs and Patient Assistance

Estimated Costs

  • Cash price: ~$6,685 for 56×20mg capsules (prices vary by quantity and location)
  • With insurance: Depends on formulary tier and copay structure

Assistance Options

  • Manufacturer programs: Check with Chiesi Global Rare Diseases for copay assistance
  • Accredo support: $2.3B in patient assistance provided in 2022
  • Foundation grants: Rare disease foundations may offer financial support

FAQ

Q: How long does Cigna prior authorization take for Mycapssa in New Jersey? A: Standard processing is 15 business days; expedited requests for urgent cases process within 72 hours.

Q: What if Mycapssa isn't on my Cigna formulary? A: Request a formulary exception through your doctor, documenting medical necessity and prior treatment failures.

Q: Can I get expedited approval if I'm currently on injectable octreotide? A: Yes, if switching from injections due to administration difficulties or side effects, mark your PA as urgent and call Cigna immediately.

Q: Does step therapy apply if I tried injectable SSAs outside New Jersey? A: Treatment records from any state are accepted; provide documentation of prior octreotide or lanreotide use and outcomes.

Q: What happens if my external appeal is denied? A: IHCAP decisions are final for state-regulated plans. Consider working with patient advocacy organizations for additional support options.

Q: How do I transfer my prescription to Accredo? A: Call Accredo at 877-826-7657 or have your doctor submit the prescription directly; allow 5-7 days for processing and delivery.

Sources & Further Reading

Disclaimer: This information is for educational purposes and is not medical advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage questions. For additional support with complex appeals, consider consulting with healthcare coverage advocates who specialize in turning denials into approvals through targeted, evidence-based submissions.

Consumer assistance: Contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467 or the IHCAP-specific line at 1-888-393-1062 for questions about the appeals process.

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