Pharmaceutical costs are currently the number one driver of benefit plan expenses for many of our clients and customers.1 At Cigna, our utilization management (UM) solutions work to push back this trend by defending against potentially harmful, ineffective or unnecessary drug treatments. This includes scrutinizing the use of medications associated with opioid abuse. UM works to address the safety concerns associated with opioid abuse.
We leverage integrated medical and pharmacy data, clinical expertise, collaboration with network health care providers, and strength from our combination with Express Scripts®. Together, these tools monitor for appropriate medication use and advise customers about lower-cost drug options with similar outcomes, when appropriate.
Our clinical edits help ensure use of the right drug, in the right dose, at the right time.
Through prior authorization (PA), we ensure the prescriber contacts Cigna for approval of certain medications in order to approve coverage. Quantity limits (QL) help make sure customers receive coverage for the right amount of medication for the right length of time. With step therapy (ST), customers must try a lower cost, clinically appropriate medication before the plan covers more expensive brand-name medications. Typically, this means starting with a generic or lower-cost preferred brand.
UM comes standard for all clients.
Cigna's UM offering is available at no additional cost. This means that baseline UM edits automatically apply to all clients, which includes refill-too-soon and cost threshold edits, as well as include important opioid management edits. Clients can then select from three comprehensive utilization management packages:
We make UM easier for customers and health care providers in these ways, and help clients optimize pharmacy benefit spend:
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 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 complete details of prescription drug coverage, contact a Cigna representative.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, (CHLIC), Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., Lynnfield Drug, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC). The Cigna name, logo, and other Cigna marks are trademarks of Cigna Intellectual Property, Inc. "Express Scripts" is a trademark of Express Scripts Strategic Development, Inc. This newsletter is not intended for residents of New Mexico.
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