Stronger utilization management to help improve savings, quality and care

Stronger utilization management to help improve savings, quality and care

At Cigna, we use insights from our connected benefits, vast clinical expertise, and strength from our combination with Express Scripts to design comprehensive utilization management (UM) solutions that help improve outcomes and reduce costs.

Right drug, right dose, right time

Our UM process focuses on total medical cost and customer safety. We proactively review integrated data on new and emerging drugs to help protect customers against potentially harmful, ineffective or unnecessary drug treatments.

  • Quantity limits: Help ensure clinically appropriate dosing and duration of use to mitigate waste and potential stockpiling of medication.
  • Prior authorization: Helps ensure clinically appropriate use of medications for improved safety.
  • Step therapy: Helps ensure use of clinically effective first-line medications before second-line coverage is considered for improved affordability.

We make UM easier for customers in the following ways, and help clients optimize pharmacy benefit spend:

  • Real-time benefit check - Cigna's new real-time benefit check makes it possible for a customer’s specific pharmacy benefit and formulary information to be included in their Electronic Health Record (EHR) at the point of prescribing. This provides physicians and customers line of sight of what their medication may cost, if it requires UM (such as a prior authorization) and if there are alternatives to save and/or to avoid UM. We see 50 to 75 percent of people move to the alternative medication when we provide clinical and cost information to doctors.1
     
  • Electronic Prior Authorization (ePA) - This is a process powered by our integrated medical and pharmacy data. If a PA is required for a chosen medication, the provider will be able to initiate and obtain a response in real time. In fact, ePA allows doctors to submit a PA in less than one minute.2
     
  • Streamlined PA with Cigna Rx Claim Connect - Cigna Rx Claim Connect uses medical and pharmacy data to avoid the need for a PA. We can avoid the PA if the demographic and clinical information in our medical and pharmacy claim databases satisfies the necessary drug management criteria. When criteria is met, the claim is paid. Approximately 56 percent of PAs are thus avoided.3
  1. Cigna National Book of Business analysis of step therapy activity, October 2018 – performance dependent on therapeutic class – subject to change.
  2. Cigna National Book of Business analysis of ePA program, full-year 2018.
  3. Based on most recent results of Cigna Rx Claims Connect reported May 2019.

“Express Scripts” is a trademark of Express Scripts Strategic Development, Inc.

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Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. Some plans require you to use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. Group medical and pharmacy plans are insured and/or administered by Cigna Health and Life Insurance Company or its affiliates. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. All pictures are used for illustrative purposes only. This website is not intended for residents of New Mexico.

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