By Counterforce Health Team in Crysvita (burosumab) —

Resources to Get Crysvita (burosumab) Covered by Cigna in New Jersey: Forms, Appeals, and Specialty Pharmacy Guide

Answer Box: Getting Crysvita Covered by Cigna in New Jersey

Eligibility: Cigna requires prior authorization for Crysvita (burosumab) for X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO). Fastest path: Submit complete PA request through Express Scripts/Accredo with specialist documentation, genetic testing, and failed conventional therapy records. Start today: Contact your endocrinologist to initiate the PA process and gather required clinical documentation. Processing typically takes 15 business days (72 hours if expedited). If denied, New Jersey offers robust appeal rights through Cigna's internal process and external review via IHCAP/Maximus.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms & Documentation
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Support Lines & Contacts
  6. Appeals Process in New Jersey
  7. Common Denial Reasons & Solutions
  8. New Jersey Consumer Assistance
  9. FAQ

Start Here: Verify Your Plan & Find Forms

Before beginning the prior authorization process, confirm your specific Cigna plan details:

Step 1: Verify Coverage

  • Log into myCigna portal to check if your plan uses Express Scripts as the pharmacy benefit manager
  • Confirm Crysvita requires prior authorization (all Cigna plans currently require PA)
  • Note your plan's specialty pharmacy (typically Accredo for Cigna members)

Step 2: Locate Current Forms Cigna updates forms annually. Always use the most current version:

  • Prior authorization forms are available through the Express Scripts provider portal
  • Cigna formulary exception forms for step therapy overrides or quantity limit increases
  • Medical appeal forms if you need to challenge a denial
Tip: Form numbers and procedures change yearly. Always verify you're using the 2024/2025 version by checking the date on the document header.

Required Forms & Documentation

Core Prior Authorization Requirements

For XLH (X-linked Hypophosphatemia):

  • Completed Cigna/Express Scripts prior authorization form
  • Specialist attestation (endocrinologist required)
  • Confirmed diagnosis with supporting documentation:
    • Genetic testing results (if available)
    • Low serum phosphate levels
    • Elevated FGF23 levels
    • Clinical evidence of rickets/osteomalacia
  • Documentation of failed conventional therapy (oral phosphate + calcitriol)
  • Patient weight and proposed dosing schedule
  • ICD-10 code: E83.30 (disorder of phosphorus metabolism)

For TIO (Tumor-Induced Osteomalacia):

  • Documentation of unresectable or non-localized tumor
  • Imaging studies
  • Biochemical confirmation
  • Age verification (≥2 years for pediatric patients)

Medical Necessity Letter Checklist

Your prescribing physician should include:

  • Patient's clinical history and current symptoms
  • Previous treatment attempts and outcomes
  • Why Crysvita is medically necessary vs. alternatives
  • Expected treatment goals and monitoring plan
  • Reference to FDA labeling and clinical guidelines

Submission Portals & Methods

Primary Submission Routes

Express Scripts Provider Portal (Recommended)

  • Fastest processing method
  • Real-time status tracking
  • Secure document upload
  • Access at Express Scripts provider portal (confirm current link with your practice)

Fax Submission

  • Use the fax number listed on the current PA form
  • Include cover sheet with member ID and urgency level
  • Keep fax confirmation receipts

Accredo Specialty Pharmacy

  • Call 1-877-315-6140 for case management
  • They can assist with PA submission and status tracking
  • Required for final drug dispensing once approved
Note: Never submit original documents. Keep copies of all submissions and confirmation receipts.

Specialty Pharmacy Setup

Accredo Onboarding Process

Once your PA is approved:

  1. Provider Setup
    • Register with Accredo if not already enrolled
    • Provide DEA number and practice information
    • Confirm delivery preferences (office vs. patient home)
  2. Patient Enrollment
    • Patient calls Accredo to complete intake
    • Insurance verification and copay discussion
    • Delivery scheduling and injection training if needed
  3. Ongoing Management
    • Regular refill coordination
    • Insurance reauthorization reminders
    • Clinical monitoring support

Transfer Instructions: If switching from another specialty pharmacy, Accredo can facilitate the transfer with proper patient authorization.

Support Lines & Contacts

Cigna Member Services

  • Main Line: 1-800-244-6224 (24/7)
  • Prior Authorization Status: 1-800-882-4462
  • TTY/TDD: Dial 711

Express Scripts/Accredo

  • Prior Authorization Status: 1-800-753-2851
  • Accredo Patient Support: 1-877-315-6140

What to Have Ready When Calling

  • Cigna member ID
  • Prescription details (drug name, strength, quantity)
  • Provider NPI number
  • Claim or reference numbers

Counterforce Health helps patients and clinicians navigate complex prior authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling medical necessity arguments that align with payer requirements.

Appeals Process in New Jersey

Cigna Internal Appeals

Timeline & Process:

  • Commercial Plans: 180 days to file internal appeal
  • Medicare Advantage: 65 days to file
  • Standard Review: 30 days for pre-service, 60 days for post-service
  • Expedited Review: 72 hours when urgent

Submission Address: Cigna National Appeals Unit
P.O. Box 188011
Chattanooga, TN 37422

New Jersey External Review (IHCAP)

If Cigna denies your internal appeal, New Jersey law provides external review through the Independent Health Care Appeals Program:

Eligibility: Fully insured New Jersey health plans (excludes self-funded employer plans and Medicare)

How to File:

  • Online: https://njihcap.maximus.com (recommended)
  • Fax: (585) 425-5296
  • Mail: Maximus Federal-NJ IHCAP, 3750 Monroe Avenue, Suite 705, Pittsford, NY 14534

Timeline: 4 months from final internal denial (some plans may have 90-day limits)

Required Documents:

  • Completed external appeal application
  • All internal appeal decisions from Cigna
  • Medical records supporting medical necessity
  • Signed consent if filed by provider or advocate
Important: External review is free to patients. If the independent medical reviewers overturn Cigna's denial, the insurer must comply and provide coverage.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient clinical documentation Submit comprehensive medical records Lab results, imaging, specialist notes
Missing genetic confirmation Provide genetic testing or clinical diagnosis criteria Genetic test results or detailed clinical assessment
Concurrent use with phosphate/vitamin D Document discontinuation timeline Provider attestation of medication cessation
Age criteria not met Verify patient age and indication Birth certificate, medical records
Not medically necessary Submit detailed medical necessity letter Clinical rationale, treatment history, guidelines

Medical Necessity Arguments

For successful appeals, Counterforce Health recommends addressing these key points:

  • Patient's functional limitations and quality of life impact
  • Failed response to conventional therapy
  • Risk of disease progression without treatment
  • Alignment with FDA-approved indications and clinical guidelines

New Jersey Consumer Assistance

State Resources

NJ Department of Banking and Insurance (DOBI)

Additional Support:

  • NJ Managed Care Ombudsman (Department of Human Services)
  • Patient advocacy organizations for rare diseases
  • Legal aid societies for complex cases

When to Contact State Regulators:

  • Cigna fails to respond within required timeframes
  • Procedural violations in the appeal process
  • Pattern of inappropriate denials

FAQ

How long does Cigna prior authorization take in New Jersey? Standard processing is 15 business days. Expedited requests (when medical urgency is documented) are processed within 72 hours.

What if Crysvita is non-formulary on my plan? Submit a formulary exception request with clinical justification. Include documentation of why formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delays would pose a serious threat to your health or ability to regain function. Document the urgency in your appeal submission.

Does step therapy apply if I failed treatments outside New Jersey? Medical records from other states are acceptable. Ensure documentation clearly shows treatment attempts and outcomes.

What happens if Cigna denies my appeal? New Jersey residents can file for external review through IHCAP/Maximus. This independent review has overturned many insurer denials when medical evidence supports coverage.

How much does Crysvita cost without insurance? Wholesale acquisition cost ranges from $4,451 (10mg) to $13,354 (30mg) per vial, with total monthly costs varying by patient weight and dosing frequency.

Are there financial assistance programs? Yes, check with Ultragenyx/Kyowa Kirin for manufacturer patient assistance programs and copay cards for eligible patients.

Can my provider file the external appeal for me? Yes, providers can file IHCAP appeals with written patient consent and proper authorization forms.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for specific coverage questions. For complex cases requiring targeted appeal strategies, Counterforce Health specializes in turning insurance denials into successful approvals through evidence-based medical necessity arguments.

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