By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by Cigna in New Jersey: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Cigna Coverage for Nucala in New Jersey

Cigna requires prior authorization for Nucala (mepolizumab) with specific clinical criteria including blood eosinophil levels ≥300 cells/μL within 6 weeks and documented failure of high-dose inhaled corticosteroids plus LABA therapy. Submit requests via CoverMyMeds or Cigna's provider portal. If denied, New Jersey residents can appeal internally (180 days) then externally through IHCAP via Maximus (4 months from final denial).

First step today: Verify your plan coverage by calling the number on your Cigna ID card and gather recent eosinophil lab results and documentation of prior asthma therapy failures.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms for Prior Authorization
  3. Submission Portals & Methods
  4. Specialty Pharmacy Enrollment with Accredo
  5. Support Contact Numbers
  6. Appeals Process: Internal & External
  7. New Jersey State Resources
  8. Common Denial Reasons & Solutions
  9. FAQ

Start Here: Verify Your Plan & Find Forms

Before submitting any paperwork, confirm your Cigna plan covers specialty medications and identify whether you have a fully-insured New Jersey plan (eligible for state external review) or a self-funded employer plan (federal ERISA rules apply).

Coverage Verification Steps:

  1. Call Cigna customer service at the number on your ID card
  2. Ask specifically about "specialty drug coverage" and "prior authorization requirements for Nucala"
  3. Request your plan's formulary tier for mepolizumab
  4. Confirm whether Express Scripts manages your prescription benefits
Note: Cigna uses Express Scripts as their pharmacy benefit manager (PBM), and Nucala typically requires specialty pharmacy dispensing through Accredo.

Required Forms for Prior Authorization

Primary PA Form

Cigna's official Nucala prior authorization form is available at: static.cigna.com/assets/chcp/pdf/resourceLibrary/prescription/Nucala.pdf

Clinical Documentation Required

Requirement Specific Details Where to Find
Blood Eosinophils ≥300 cells/μL within past 6 weeks OR pre-treatment Recent CBC with differential
Prior Therapy High-dose ICS + LABA for ≥3 months with documented failure Pharmacy records, clinic notes
Exacerbation History ≥2 exacerbations/year requiring oral steroids Emergency department visits, steroid prescriptions
Age Requirement ≥18 years for severe eosinophilic asthma Date of birth verification
Diagnosis Code ICD-10 for severe asthma with eosinophilia Provider documentation

Medical Necessity Letter Checklist

Your prescriber should include:

  • Patient's specific eosinophil count and date
  • Documentation of inadequate asthma control despite optimized therapy
  • Previous biologic failures (if applicable)
  • Contraindications to alternative treatments
  • Expected treatment goals and monitoring plan

Submission Portals & Methods

  1. CoverMyMeds: www.covermymeds.com - Search for "Cigna Nucala form"
  2. SureScripts: Available through most EHR systems
  3. Cigna Provider Portal: cignaforhcp.cigna.com

Fax Submission

  • Standard PA requests: Check current fax number on the PA form (verify with source linked above)
  • Appeals: Use fax numbers provided in denial letters

Processing Times:

  • Standard review: 7-14 days
  • Expedited review: 72 hours (if health would be jeopardized)
  • Incomplete submissions: 5-10 additional days

Specialty Pharmacy Enrollment with Accredo

Once your prior authorization is approved, Cigna will direct you to Accredo for specialty pharmacy services.

Enrollment Process

  1. Provider enrollment: Use GSK's Together with NUCALA portal at togetherwithgsk.com/nucala/hcp/enroll
  2. Accredo referral: Fax completed enrollment form to 866-531-1025
  3. Required documents: Front and back of insurance cards, patient demographics, prescriber information

Patient Portal Setup

Accredo will contact you directly to:

  • Verify insurance benefits
  • Coordinate delivery scheduling
  • Provide injection training if needed
  • Set up automatic refills
Tip: Enroll early in the week to avoid processing delays over weekends.

Support Contact Numbers

For Providers

  • General Provider Services: 1-800-882-4462 (24/7)
  • Prior Authorization Status: Same number, have member ID ready
  • Precertification Fax: 1-866-873-8279

For Patients

  • Member Services: Number on your Cigna ID card
  • Specialty Pharmacy (Accredo): Number provided after enrollment
  • Coverage Questions: 1-800-244-6224

GSK Support

  • Together with NUCALA: Patient enrollment and copay assistance
  • Provider Support: Clinical and access resources

Appeals Process: Internal & External

Internal Appeals (Cigna)

Timeline: File within 180 days of denial Process:

  1. Submit written appeal with denial letter and supporting documentation
  2. First level review: 30 days for response
  3. Second level review: Additional 30 days if needed

Required Documents:

  • Original denial letter
  • Updated medical records
  • Physician statement addressing denial reasons
  • Any new clinical evidence

External Review (New Jersey IHCAP)

For fully-insured New Jersey plans only.

Eligibility:

  • Completed internal appeals process
  • Denial based on medical necessity or experimental/investigational determination
  • File within 4 months of final internal denial

How to File:

  1. Online: njihcap.maximus.com
  2. Phone: 888-866-6205
  3. Email: [email protected]

Timeline:

  • Preliminary review: 5 business days
  • Standard decision: 45 calendar days
  • Expedited review: 48 hours for urgent cases

Fee: $25 (waivable for financial hardship)

New Jersey State Resources

Consumer Assistance

  • NJ Department of Banking and Insurance: 1-800-446-7467
  • IHCAP Hotline: 1-888-393-1062
  • Online complaints: nj.gov/dobi

State Protections

New Jersey's step therapy law provides additional protections for patients who have tried and failed formulary alternatives. Your prescriber can request step therapy overrides based on:

  • Previous treatment failure
  • Contraindications to preferred drugs
  • Drug interactions
  • Adverse effects from required medications

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that address specific payer requirements, helping patients navigate complex prior authorization processes more effectively.

Common Denial Reasons & Solutions

Denial Reason Required Evidence Action Steps
Eosinophil count not documented Recent CBC with differential showing ≥300 cells/μL Submit lab results within 6 weeks of request
Step therapy not completed Pharmacy records showing ICS/LABA trials Provide prescription history and failure documentation
Not medically necessary Specialist evaluation and treatment history Include pulmonologist/allergist consultation notes
Quantity limit exceeded Dosing justification based on weight/severity Submit clinical rationale for prescribed dose
Non-formulary drug Alternative therapy contraindications Document why formulary options are inappropriate

From Our Advocates

"We've seen many Nucala appeals succeed when providers include specific eosinophil trends over time, not just a single lab value. Showing persistently elevated counts despite standard therapy strengthens the medical necessity argument significantly."

Frequently Asked Questions

How long does Cigna prior authorization take for Nucala in New Jersey? Standard review takes 7-14 days. Expedited review (when delay would harm health) takes 72 hours. Submit complete documentation to avoid delays.

What if Nucala is not on Cigna's formulary? Request a formulary exception by documenting why formulary alternatives are medically inappropriate. Include evidence of previous failures or contraindications.

Can I appeal while continuing current treatment? Yes, continue your current asthma medications during the appeal process. Don't stop prescribed treatments while waiting for Nucala approval.

Does step therapy apply if I've tried biologics outside New Jersey? Yes, document all previous biologic trials regardless of where they occurred. Include pharmacy records and clinical notes from other states.

What counts as "medical necessity" for Nucala? Severe eosinophilic asthma with elevated blood eosinophils (≥300 cells/μL), inadequate control despite optimized standard therapy, and ≥2 exacerbations per year.

How do I request a peer-to-peer review? Your prescriber can request to speak directly with a Cigna medical director by calling provider services at 1-800-882-4462 and asking for peer-to-peer review.

What if my employer plan is self-funded? Self-funded plans follow federal ERISA rules, not New Jersey state protections. You cannot use IHCAP external review but may have other appeal rights through your employer.

Are there copay assistance programs for Nucala? Yes, GSK offers copay assistance through their Together with NUCALA program. Eligibility restrictions may apply based on insurance type.

When dealing with complex prior authorization requirements, platforms like Counterforce Health can help by analyzing your specific denial and crafting targeted appeals that address payer-specific criteria, potentially saving weeks of back-and-forth communication.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For questions about New Jersey insurance regulations, contact the Department of Banking and Insurance at 1-800-446-7467.

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