By Counterforce Health Team in Givlaari (givosiran) —

Resources to Get Givlaari (givosiran) Approved with Cigna in New Jersey: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Givlaari (givosiran) Covered by Cigna in New Jersey

To get Givlaari approved by Cigna in New Jersey:

  1. Verify coverage through your myCigna account - most plans require Accredo specialty pharmacy
  2. Submit prior authorization via CoverMyMeds or fax with specialist consultation notes, attack documentation, and elevated ALA/PBG labs
  3. If denied, file internal appeal within 180 days, then pursue New Jersey's external review through Maximus IHCAP

Key requirements: Age 18+, confirmed acute hepatic porphyria diagnosis, 1-2 documented attacks in past 6 months, porphyria specialist involvement, and elevated urinary/plasma PBG or ALA levels.

Table of Contents

Verify Your Plan and Find Forms

Start by confirming your Cigna plan's specific requirements for Givlaari (givosiran). Most Cigna commercial plans route specialty medications through Express Scripts or require Accredo specialty pharmacy for coverage.

Step 1: Check Your Coverage

  • Log into your myCigna account to verify specialty drug benefits
  • Look for "Specialty Pharmacy" in your plan documents
  • Confirm whether prior authorization is required (it typically is for Givlaari)

Step 2: Locate Current Forms The most up-to-date Cigna prior authorization forms are available through:

Note: Forms update regularly. Always verify you're using the current version before submitting.

Prior Authorization Forms and Requirements

Coverage at a Glance

Requirement Details Documentation Needed
Age 18+ years Date of birth verification
Diagnosis Confirmed acute hepatic porphyria (all subtypes) ICD-10 codes, genetic testing results
Prescriber Porphyria specialist or consultation Specialist consultation notes
Attack History 1-2 documented attacks in past 6 months Hospital records, hemin administration records
Lab Confirmation Elevated ALA/PBG within past year Laboratory reports
Approval Duration 6 months initial, 12 months renewal Clinical response documentation for renewal

Medical Necessity Documentation Checklist

Your prescriber must provide:

Clinical Evidence:

  • Confirmed AHP diagnosis with genetic testing or biochemical confirmation
  • Documentation of qualifying porphyria attacks requiring hospitalization, urgent care, or IV hemin
  • Elevated urinary or plasma porphyrinogen (PBG) or delta-aminolevulinic acid (ALA) levels
  • Evidence of specialist consultation (hematologist, hepatologist, or gastroenterologist)

Treatment History:

  • Prior therapies attempted and outcomes
  • Contraindications to alternative treatments
  • Current medication regimen and monitoring plan

Submission Portals and Methods

Electronic Submission (Preferred)

  • CoverMyMeds: Most efficient method with real-time status updates
  • SureScripts via EHR: Direct integration from electronic health records
  • Cigna Provider Portal: Access through myCigna provider login

Traditional Methods

  • Fax: 1-800-882-4462 (verify current number with Cigna)
  • Phone: 1-800-882-4462 for verbal prior authorization requests
  • Mail: Address provided on specific PA forms (varies by region)
Tip: Electronic submissions typically process faster and provide better tracking capabilities than fax or mail.

Specialty Pharmacy Setup with Accredo

Most Cigna plans require Givlaari to be filled through Accredo specialty pharmacy for coverage optimization.

Onboarding Process

Step 1: Prescription Transfer

  • Your prescriber e-prescribes to Accredo (NCPDP 4436920)
  • Alternative: Fax prescription to 888-302-1028
  • Phone orders: 866-759-1557

Step 2: Prior Authorization Coordination

  • Accredo coordinates with Cigna for PA approval
  • Clinical documentation forwarded automatically
  • Patient receives status updates via phone and mail

Step 3: Delivery Setup

  • Home delivery or physician office delivery available
  • Specialized handling for temperature-sensitive medications
  • 24/7 clinical support and administration training

Patient Support Services

  • Copay assistance program coordination
  • Insurance verification and benefit explanation
  • Refill reminders and adherence support
  • Clinical pharmacist consultations

Appeals Process: Internal and External

Cigna Internal Appeals

Timeline: File within 180 days of initial denial Review Period: 60 days for standard, expedited available for urgent cases Required Documentation:

New Jersey External Review (IHCAP)

After completing Cigna's internal appeals, New Jersey residents can access the state's Independent Health Care Appeals Program through Maximus.

Key Details:

  • Filing Deadline: 4 months (180 days) from final internal denial
  • Cost: $25 filing fee (waivable for financial hardship)
  • Timeline: 45 days standard, 48 hours expedited
  • Decision: Binding on Cigna if overturned

Contact Information:

Required Documentation:

  • Completed external appeal application
  • Copy of final internal denial letter
  • Medical records and physician statement
  • Any additional supporting clinical evidence

Key Contact Numbers

Cigna Member Services

  • General Member Services: 1-800-244-6224 (24/7)
  • Provider Services: 1-800-882-4462
  • TTY/TDD: Dial 711

Specialty Pharmacy (Accredo)

  • Patient Services: 877-826-7657
  • Prescriber Line: 866-759-1557
  • Fax: 888-302-1028

New Jersey State Resources

  • NJ IHCAP Hotline: 888-393-1062
  • NJ Department of Banking and Insurance: 609-777-9470
  • Consumer Assistance: 1-800-446-7467

New Jersey State Resources

New Jersey provides robust consumer protections for insurance appeals and external reviews.

Department of Banking and Insurance (DOBI)

Consumer Rights in New Jersey

  • Right to expedited appeal for urgent medical situations
  • Provider can file appeals on patient's behalf with consent
  • External review decisions are binding on insurance companies
  • No cost to consumer for external review process (beyond filing fee)

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed appeals that address payer requirements point-by-point. The platform streamlines the appeals process by pulling relevant clinical guidelines, FDA labeling, and peer-reviewed studies to support medical necessity arguments.

Common Denial Reasons and Solutions

Denial Reason Required Documentation Where to Find It
Missing biochemical confirmation Elevated ALA/PBG lab results Hospital/clinic lab reports from past year
Insufficient attack history Documentation of 1-2 qualifying attacks Emergency department records, hemin administration logs
Non-specialist prescriber Specialist consultation Hematology, hepatology, or gastroenterology consultation notes
Continuation with hemin Treatment plan modification Updated specialist recommendation for hemin discontinuation

Medical Necessity Letter Template Points

When writing appeals, address these key elements:

  1. Diagnosis confirmation with genetic testing or biochemical markers
  2. Attack frequency and severity with specific dates and interventions
  3. Prior treatment failures or contraindications to alternatives
  4. Specialist involvement and ongoing monitoring plan
  5. Treatment goals and expected outcomes with Givlaari

FAQ

Q: How long does Cigna prior authorization take for Givlaari in New Jersey? A: Standard PA decisions are typically made within 72 hours for non-urgent requests and 24 hours for expedited requests, as required by New Jersey regulations.

Q: What if Givlaari is non-formulary on my Cigna plan? A: You can request a formulary exception through Cigna's medical necessity review process, requiring documentation that formulary alternatives are inappropriate or ineffective.

Q: Can I request an expedited appeal if my condition is urgent? A: Yes, both Cigna internal appeals and New Jersey external reviews offer expedited processes when delays would jeopardize health.

Q: Does step therapy apply to Givlaari? A: Many Cigna plans require documentation of hemin use or contraindications to hemin before approving Givlaari, effectively creating a step therapy requirement.

Q: What happens if my external appeal is successful? A: Cigna must comply with the external reviewer's decision and provide coverage. The decision is legally binding under New Jersey law.

Q: Can my doctor file appeals on my behalf? A: Yes, New Jersey allows healthcare providers to file external appeals with patient consent, streamlining the process for complex cases.

From our advocates: "We've seen Givlaari appeals succeed when clinicians provide detailed attack logs with specific dates, interventions, and outcomes. One case was initially denied for 'insufficient attack history' but approved on appeal when the specialist documented three emergency department visits with hemin administration over six months, including lab values showing elevated ALA during attacks."

For additional support navigating the appeals process, Counterforce Health offers specialized assistance in turning insurance denials into targeted, evidence-backed appeals by analyzing payer policies and crafting responses that address specific coverage criteria.

Sources & Further Reading:

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and change over time. Always consult your healthcare provider and insurance plan documents for the most current information specific to your situation.

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