By Counterforce Health Team in Opsumit (macitentan) —

How to Get Opsumit (Macitentan) Covered by Cigna in Michigan: Forms, Appeals & State Review Process

Answer Box: Getting Opsumit (Macitentan) Covered by Cigna in Michigan

Fastest path to approval: Submit prior authorization through Cigna with right heart catheterization results, WHO functional class II-III documentation, and specialist prescription from a cardiologist or pulmonologist. If denied, you have 180 days to appeal internally, then 127 days for Michigan's external review through DIFS. Start by calling Cigna member services and requesting the PA form, or have your clinic submit through the provider portal.

First step today: Contact your prescribing physician to ensure they have your PAH diagnosis confirmation via right heart catheterization and can document your WHO functional class status.

Table of Contents

  1. Understanding Cigna's Opsumit Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Playbook for Cigna in Michigan
  5. Medical Necessity Letter Essentials
  6. Michigan's External Review Process
  7. Scripts & Templates
  8. When to Escalate
  9. FAQ

Understanding Cigna's Opsumit Requirements

Opsumit (macitentan) requires prior authorization from Cigna, with approval typically lasting one year. As an endothelin receptor antagonist for pulmonary arterial hypertension, it falls under Cigna's specialty drug management through Express Scripts/Accredo.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Cigna member portal Cigna PA Guide
WHO Group 1 PAH Must have confirmed diagnosis Right heart catheterization results Cigna PAH Policy
Specialist Prescription Cardiologist or pulmonologist Provider credentials Cigna Coverage Criteria
Right Heart Cath Confirms PAH diagnosis Hospital/clinic records Cigna PAH Requirements
REMS Enrollment Pregnancy risk program Opsumit REMS website FDA requirement

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

  • Insurance card and member ID
  • Right heart catheterization results showing PAH confirmation
  • WHO functional class documentation (Class II or III typically required)
  • Complete medication history, including failed therapies
  • Timeline: 1-2 days to collect

2. Confirm Specialist Prescriber (Clinic)

  • Ensure prescriber is cardiologist or pulmonologist
  • If not, arrange consultation or referral
  • Timeline: Same day to 2 weeks depending on availability

3. Submit Prior Authorization (Clinic)

  • Complete Cigna PA form through provider portal
  • Include all supporting documentation
  • Timeline: 1-2 business days to submit
  • Expected response: 30 days for standard review, 24 hours for expedited

4. REMS Program Enrollment (Patient + Clinic)

  • Enroll in Opsumit REMS program if female of childbearing potential
  • Complete pregnancy testing requirements
  • Timeline: 1-3 days

5. Specialty Pharmacy Coordination (Patient)

  • Work with Accredo or designated specialty pharmacy
  • Coordinate delivery and administration
  • Timeline: 3-7 days once approved
Tip: Request expedited review if your condition could worsen during standard 30-day review period. Your doctor must provide written justification.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing REMS documentation Complete REMS enrollment REMS confirmation, pregnancy test results
Insufficient PAH confirmation Submit diagnostic workup Right heart catheterization report with hemodynamics
Non-specialist prescriber Get specialist consultation Cardiologist/pulmonologist evaluation
Lack of functional class documentation Document current symptoms WHO functional class assessment form
Step therapy not completed Document prior failures Medical records showing ambrisentan/bosentan trials
Quantity limit exceeded Justify dosing Clinical rationale for specific dose/frequency

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals that address each payer's specific requirements. Their platform helps patients and providers navigate complex prior authorization processes more effectively.

Appeals Playbook for Cigna in Michigan

Internal Appeals Process

First-Level Appeal

  • Deadline: 180 calendar days from denial notice
  • Timeline: 30 days for pre-service, 60 days for post-service
  • How to file: Call member services or submit written appeal
  • Required: Original denial letter, medical records, physician statement

Second-Level Appeal

  • Deadline: 60 days after first-level denial
  • Timeline: 30 days for decision
  • How to file: Written request to Cigna appeals department
  • Required: All previous documentation plus additional clinical evidence

Expedited Appeals

  • When available: Urgent medical situations
  • Timeline: 24-72 hours for decision
  • Requirement: Physician certification of urgency

Michigan External Review

After exhausting Cigna's internal appeals, Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

Standard External Review

  • Deadline: 127 days from final Cigna denial
  • Timeline: Up to 60 days for decision
  • Cost: Free to patients
  • How to file: DIFS Form FIS 0018

Expedited External Review

  • Deadline: 10 days from final denial
  • Timeline: 72 hours for decision
  • Requirement: Physician verification of urgency
  • Contact: 877-999-6442
Note: Michigan's 127-day deadline is longer than the federal 120-day standard, giving patients extra time to file.

Medical Necessity Letter Essentials

Your physician's medical necessity letter should address these key points:

Clinical Documentation Checklist

  • PAH Diagnosis: WHO Group 1 confirmed by right heart catheterization
  • Functional Status: Current WHO functional class (II or III typically required)
  • Prior Therapies: Documentation of failed or contraindicated alternatives
  • Contraindications: Specific reasons other ERAs cannot be used
  • Treatment Goals: Expected outcomes and monitoring plan
  • Guideline Support: Reference to 2022 ESC/ERS PAH guidelines

Essential Clinical Data Points

  • Mean pulmonary arterial pressure >20 mmHg
  • Pulmonary arterial wedge pressure ≤15 mmHg
  • Pulmonary vascular resistance >2 Wood units
  • 6-minute walk test baseline results
  • Current symptom severity and functional limitations

Scripts & Templates

Patient Script for Cigna Member Services

"Hi, I'm calling about prior authorization for Opsumit, generic name macitentan, for pulmonary arterial hypertension. My member ID is [ID number]. Can you tell me the status of my PA request submitted on [date]? If it was denied, I'd like to understand the specific reasons and start the appeal process. Can you also confirm the deadline for filing an appeal?"

Clinic Staff Script for Peer-to-Peer Review

"I'm requesting a peer-to-peer review for [patient name], member ID [number], for Opsumit macitentan denial. The patient has WHO Group 1 PAH confirmed by right heart catheterization, is functional class [II/III], and has failed [specific prior therapies]. The prescribing physician is Dr. [name], a [cardiologist/pulmonologist]. When is the earliest available slot for the peer-to-peer call?"

When to Escalate

Contact Michigan DIFS if you experience:

  • Cigna missing appeal deadlines
  • Requests for inappropriate documentation
  • Denial of expedited review for urgent situations
  • Procedural violations during appeals process

Michigan DIFS Contact Information:

The Counterforce Health platform can help identify when payer requirements exceed standard medical necessity criteria and provide documentation to support escalation to state regulators.

FAQ

How long does Cigna prior authorization take for Opsumit in Michigan? Standard review takes up to 30 days. Expedited review (with physician urgency certification) takes 24 hours. Source: Cigna PA timelines

What if Opsumit is non-formulary on my Cigna plan? You can request a formulary exception through your physician. The request must include clinical justification for why formulary alternatives are inappropriate. Cigna reviews these within 72 hours.

Can I request an expedited appeal in Michigan? Yes, if your physician certifies that waiting for standard review could seriously jeopardize your health. Both Cigna internal appeals and Michigan external reviews offer expedited pathways.

Does step therapy apply if I've tried ERAs outside Michigan? Yes, documented trials of ambrisentan or bosentan from any provider should satisfy step therapy requirements. Ensure your current physician has complete records of previous treatments.

What happens if Michigan's external review upholds the denial? The external review decision is binding on Cigna. However, you may still explore alternative coverage options like manufacturer assistance programs or different insurance plans during open enrollment.

How much does Opsumit cost without insurance? Opsumit is a specialty medication with significant cost. Contact Janssen (the manufacturer) about their patient assistance programs, or explore foundation grants for PAH patients.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance.

Sources & Further Reading

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