By Counterforce Health Team in Opfolda (miglustat) —

How to Get Opfolda (Miglustat) Covered by Cigna in Georgia: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Opfolda (Miglustat) Covered by Cigna in Georgia

Eligibility: Opfolda is only approved for adults with late-onset Pompe disease (≥40 kg) who aren't improving on current enzyme replacement therapy and must be used with Pombiliti infusions.

Fastest Path: Your doctor submits a prior authorization through CoverMyMeds or calls Cigna at 1-800-882-4462. Include documentation of failed/inadequate ERT, weight ≥40 kg, and specialist confirmation that Opfolda will be co-administered with Pombiliti.

Start Today: Contact your prescribing physician to gather your ERT treatment history, current symptoms, and weight documentation—these are required for the PA request.

Table of Contents

  1. Verify Your Cigna Plan and Formulary Status
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Electronic Options
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Enrollment (Accredo)
  6. Member Services and Support Lines
  7. Georgia External Review and Appeals
  8. When to Contact State Regulators
  9. FAQ: Common Questions

Verify Your Cigna Plan and Formulary Status

Before starting your Opfolda request, confirm your plan details and formulary tier:

Check Your Coverage:

Key Coverage Requirements:

  • Must be prescribed with Pombiliti (cipaglucosidase alfa)
  • Patient weight ≥40 kg (88 lbs)
  • Documented inadequate response to current ERT
  • Adult diagnosis of late-onset Pompe disease
Note: Opfolda alone is not effective and will be denied if requested without Pombiliti co-administration.

Prior Authorization Forms and Requirements

CoverMyMeds Portal: Your physician can submit requests at covermymeds.com/main/prior-authorization-forms/cigna/

SureScripts Integration: Available through most electronic health record systems

Paper Forms

If electronic submission isn't available, your doctor can use Cigna's standard prior authorization form. Contact Cigna at 1-800-882-4462 to request the current form or download from their provider resources portal.

Required Clinical Documentation

Your physician must include:

  • Diagnosis: Late-onset Pompe disease with ICD-10 code
  • Current Treatment History: Details of previous ERT (Nexviazyme, Lumizyme) including duration, dosing, and response
  • Inadequate Response Documentation: Objective measures showing lack of improvement (6-minute walk test, pulmonary function, muscle strength assessments)
  • Weight Verification: Current weight ≥40 kg
  • Dosing Plan: Weight-based dosing (195 mg for 40-<50 kg; 260 mg for ≥50 kg) every other week, 1 hour before Pombiliti infusion

Submission Portals and Electronic Options

Primary Submission Methods

Electronic Prior Authorization:

Provider Phone Line:

  • Express Scripts Pharmacy Help Desk: 1-800-922-1557 (24/7 for Medicare Part D and commercial plans)
  • Cigna Provider Services: 1-800-882-4462

Processing Timelines

Standard Review: 2 business days after receipt of complete information Expedited Review: 24 hours for urgent medical situations

Fax Numbers and Mailing Addresses

Fax Submission

For paper prior authorization forms, fax to the number provided on your specific Cigna form. Common fax numbers include:

  • General PA Requests: Check your plan-specific form for the correct fax number
  • Accredo Specialty Pharmacy: 888-302-1028 for prescription and enrollment forms

Cover Sheet Tips

Include on your fax cover sheet:

  • Patient name and Cigna member ID
  • Prescriber name and NPI number
  • "URGENT: Prior Authorization Request - Opfolda (Miglustat)"
  • Total pages being transmitted

Specialty Pharmacy Enrollment (Accredo)

Most Cigna plans require specialty medications like Opfolda to be dispensed through Accredo Specialty Pharmacy.

Enrollment Process

For Prescribers:

  1. Log in or register at MyAccredoPatients.com
  2. Complete the Accredo Specialty Pharmacy Prescription & Enrollment Form
  3. Fax completed form to 888-302-1028
  4. Alternative: Call Accredo Physician Service Center at 844-516-3319

For Patients:

  1. Call Accredo at 844-516-3319 to initiate enrollment
  2. An Accredo patient care advocate will contact you to schedule delivery
  3. Access your account through the myCigna app or MyAccredoPatients.com

Transfer from Other Pharmacies

If your prescription was previously filled elsewhere, Accredo will contact your prescriber for a new prescription if refills aren't transferable.

When it comes to navigating complex prior authorization requirements for specialty medications like Opfolda, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with each insurer's specific requirements, potentially saving weeks of back-and-forth communication.

Member Services and Support Lines

Primary Contact Numbers

General Member Services: 1-800-244-6224 24/7 Cigna Healthcare Customer Service: 1-800-997-1654 Precertification and Prior Authorizations: 1-866-494-2111 (select "Specialist Referral" prompt)

Specialized Support

Health Advocate Support: 1-855-673-3063 (no additional cost) TTY/TDD Service: Dial 711 and follow prompts (available 24/7)

What to Ask When You Call

  • "What is the current prior authorization status for Opfolda (miglustat)?"
  • "What additional documentation is needed?"
  • "Can you provide the specific denial reason and PA criteria?"
  • "Is there a case manager I can speak with about this specialty medication?"

Georgia External Review and Appeals

If Cigna denies your Opfolda request, you have appeal rights under Georgia law.

Internal Appeals Process

Timeline: File within 180 days of denial Levels: First-level and second-level internal reviews available Expedited Options: Available for urgent medical situations

Georgia External Review

Deadline: 60 days from receiving your internal appeal denial Process: File with the Georgia Department of Insurance Cost: Free for consumers Timeline: 30 business days for standard review; 72 hours for expedited

Required Documentation for Appeals

  • Copy of original denial letter
  • Medical records authorization
  • Supporting clinical documentation
  • Specialist letter explaining medical necessity
From our advocates: We've seen Georgia patients successfully overturn Cigna denials for specialty medications by including detailed ERT failure documentation and weight-based dosing rationale in their external review submissions. The key is demonstrating that Opfolda meets the specific criteria outlined in Cigna's medical policy.

When to Contact State Regulators

Georgia Department of Insurance

Consumer Services: 1-800-656-2298 Online Complaint Form: Available at oci.georgia.gov External Review Application: Contact [email protected]

Additional Consumer Support

Georgians for a Healthy Future: Provides consumer assistance with insurance appeals and can offer one-on-one guidance Georgia Legal Services Program: Available for Medicaid/PeachCare appeals

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Diagnosis Late-onset Pompe disease ICD-10 code, genetic testing
Weight ≥40 kg (88 lbs) Current weight documentation
Prior Therapy Inadequate response to ERT Treatment history, outcome measures
Co-administration Must be used with Pombiliti Concurrent prescription required
Age Adults only Date of birth verification
Dosing Weight-based: 195mg or 260mg Prescriber calculation documentation

FAQ: Common Questions

How long does Cigna prior authorization take in Georgia? Standard review: 2 business days. Expedited review: 24 hours for urgent situations.

What if Opfolda is non-formulary on my plan? Your doctor can request a formulary exception with clinical justification. Standard review is completed within 72 hours.

Can I request an expedited appeal in Georgia? Yes, if your condition may seriously jeopardize your health or you're currently receiving treatment. Contact Cigna member services to initiate.

Does step therapy apply if I've tried ERT outside Georgia? Treatment history from any location counts toward step therapy requirements. Provide complete documentation of previous therapies.

What happens if my external review is approved? Cigna is legally required to cover the service. Georgia law makes the external review decision binding on insurers.

Can I appeal while continuing my current ERT? Yes, continue your current treatment while pursuing Opfolda approval. Document any changes in your condition during the appeal process.

How do I transfer my prescription to Accredo? Call Accredo at 844-516-3319. They'll coordinate with your prescriber to obtain a new prescription if needed.

What if I need help with the appeals process? Contact Counterforce Health for assistance with evidence-backed appeals, or call Georgia DOI Consumer Services at 1-800-656-2298.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.