By Counterforce Health Team in Opsumit (macitentan) —

How to Get Opsumit (Macitentan) Covered by Cigna in New Jersey: Complete Approval Guide with Forms and Appeals

Quick Answer: Cigna requires prior authorization for Opsumit (macitentan) in New Jersey. You need: (1) PAH specialist prescription, (2) right heart catheterization results, (3) monthly pregnancy testing documentation (females), and (4) prior therapy records. Submit through your doctor or EviCore portal. If denied, you have 180 days for internal appeals, then external review through New Jersey's IHCAP program.

Table of Contents

How to Use This Guide

This guide helps New Jersey patients and their doctors navigate Cigna's approval process for Opsumit (macitentan), a medication for pulmonary arterial hypertension (PAH). Start with the eligibility triage below to determine your approval likelihood, then follow the appropriate section for next steps.

Note: This information is current as of 2024. Insurance policies change regularly—always verify requirements with your specific Cigna plan.

Eligibility Triage: Do You Qualify?

Likely Eligible ✅

You probably qualify if you have:

  • Confirmed WHO Group 1 PAH diagnosis with right heart catheterization results
  • Prescription from a cardiologist or pulmonologist
  • Documentation of prior PAH therapy trials (60+ days on other oral PAH medications)
  • For females: established monthly pregnancy testing protocol

Possibly Eligible ⚠️

You may qualify with additional documentation if:

  • Your PAH diagnosis is recent but catheterization confirms WHO Group 1
  • You've tried some PAH medications but documentation is incomplete
  • Your current specialist hasn't prescribed PAH medications before

Not Yet Eligible ❌

You'll need more preparation if:

  • PAH diagnosis relies only on echocardiogram (catheterization required)
  • No specialist involvement yet
  • Haven't tried other PAH medications (step therapy may apply)

If You're Likely Eligible: Document Checklist

Required Clinical Documentation

For Your Doctor to Gather:

  • Right heart catheterization report showing mean PA pressure ≥20 mmHg
  • WHO functional class assessment (II-IV)
  • Prior PAH medication trials with specific dates and outcomes
  • Current specialist consultation notes
  • For females: baseline and monthly pregnancy test results

Pregnancy Testing Requirements (Females): The REMS program was discontinued in April 2025, but pregnancy testing remains mandatory due to embryo-fetal toxicity risks:

  • Negative pregnancy test before starting
  • Monthly tests during treatment
  • One test one month after discontinuation
  • Effective contraception documentation

Submission Process

  1. Doctor submits prior authorization through EviCore by Evernorth portal or by calling Cigna
  2. Standard review timeline: 72 hours for formulary exceptions
  3. Expedited review: 24 hours if serious health risk documented

If You're Possibly Eligible: Tests to Request

Missing Diagnostic Requirements

Ask your doctor about:

  • Right heart catheterization if only echocardiogram was done
  • Referral to PAH specialist (cardiologist or pulmonologist)
  • Six-minute walk test for functional assessment
  • Complete medication trial documentation

Timeline to Reapply

  • Allow 2-4 weeks for additional testing
  • Specialist referrals may take 4-8 weeks in New Jersey
  • Resubmit PA request once all documentation is complete

If You're Not Yet Eligible: Alternative Options

Step Therapy Alternatives

Cigna may require trials of these medications first:

  • PDE5 inhibitors: sildenafil, tadalafil
  • Other ERAs: ambrisentan, bosentan
  • Prostacyclin pathway drugs: epoprostenol, treprostinil

Exception Request Strategy

Your doctor can request a formulary exception if:

  • Previous medications caused adverse effects
  • You have contraindications to step therapy options
  • Clinical evidence supports Opsumit as first-line therapy

If You're Denied: New Jersey Appeal Process

Internal Appeals (First Step)

Timeline: 180 days from denial date Process:

  1. Call Cigna member services (number on ID card)
  2. Request first-level internal appeal
  3. Submit additional clinical documentation
  4. Consider peer-to-peer review request

External Review Through IHCAP

New Jersey offers excellent external appeal rights through the Independent Health Care Appeals Program (IHCAP).

When to Use: After completing Cigna's internal appeals Timeline: 4 months (180 days) from final internal denial Process:

  1. Contact Maximus at 888-866-6205
  2. Submit application online or by mail
  3. Independent physician reviewers evaluate your case
  4. Decision within 45 days (expedited available)

Cost: Free to patients—insurers pay all review costs

From our advocates: We've seen many New Jersey PAH patients succeed at external review by including detailed specialist letters explaining why Opsumit specifically addresses their clinical needs better than alternatives. The key is connecting your unique medical situation to established treatment guidelines.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Approval needed before filling Doctor submits via EviCore portal Cigna PA Requirements
Right Heart Cath Diagnostic test confirming PAH Hospital cardiology department Cigna PAH Policy
Specialist Prescription Cardiologist or pulmonologist PAH specialist referral Coverage Criteria
Pregnancy Testing Monthly tests (females) OB/GYN or primary care FDA Safety Requirements
Prior Therapy 60+ days other PAH meds Medical records documentation Step Therapy Policy

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documents Needed
"No specialist consultation" Get PAH specialist referral Cardiologist/pulmonologist consultation note
"Insufficient prior therapy" Document medication trials Pharmacy records, clinic notes showing dates/outcomes
"Diagnosis not confirmed" Submit catheterization results Right heart cath report with specific pressures
"REMS not enrolled" Update on program discontinuation REMS discontinuation notice + pregnancy testing records
"Not medically necessary" Clinical justification letter Specialist letter citing PAH guidelines and patient-specific factors

FAQ: Cigna Opsumit Coverage in New Jersey

How long does Cigna prior authorization take in New Jersey? Standard formulary exceptions are reviewed within 72 hours. Expedited reviews for urgent cases are completed within 24 hours.

What if Opsumit is non-formulary on my Cigna plan? Your doctor can request a formulary exception with clinical justification for why Opsumit is more appropriate than formulary alternatives.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and New Jersey's IHCAP external review offer expedited pathways when delays could seriously jeopardize your health.

Does step therapy apply if I tried medications outside New Jersey? Yes, medication trials from other states count toward step therapy requirements if properly documented in your medical records.

What happens if IHCAP overturns Cigna's denial? The decision is binding—Cigna must cover Opsumit according to New Jersey statute N.J.S.A. 26:2S-11.

How much does Opsumit cost with Cigna coverage? Costs vary by plan tier and deductible. Contact Cigna member services for your specific copay information.

Resources & Next Steps

Getting specialized medications covered requires persistence and proper documentation. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Key New Jersey Contacts:

  • Cigna Member Services: Number on your ID card
  • IHCAP External Appeals: 888-866-6205
  • NJ Insurance Consumer Hotline: 1-800-446-7467
  • IHCAP Information: 1-888-393-1062

Essential Links:

For complex denials or appeals, consider working with organizations like Counterforce Health that specialize in insurance authorization strategies and can help craft compelling clinical arguments tailored to your specific situation.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary by plan and change regularly. Always verify current requirements with your specific Cigna plan and consult your healthcare provider for medical decisions. For official New Jersey insurance information, visit the Department of Banking and Insurance website.

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