Monitoring care and costs through Utilization Management

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:

  • The Essential Protection package is recommended for all clients and is Cigna’s standard offering. It helps improve pharmacy benefit plan affordability and protection – delivering an estimated 2.5%–3% annual savings.2 This package includes the recommended level of QL, PA and ST edits for optimal protection and savings.
  • The Limited Protection package is for clients who want PA and QL, but wish to exclude ST. 
  • The Complete Protection package helps improve pharmacy benefit plan affordability and offers maximum protection – delivering an estimated 3%–3.5% annual savings.3 It is available for clients seeking maximum clinical oversight and affordability. It offers the same protection as the Essential package, plus additional ST and PA edits, including management of narrow therapeutic index medications – drugs where small differences in dose or blood concentration may pose serious or life-threatening consequences.

We make UM easier for customers and health care providers in these ways, and help clients optimize pharmacy benefit spend:

  • Real-time benefit check – Cigna's 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 gives providers and customers an idea of what their medication may cost, if it requires UM (such as a PA) 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.4
  • 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 and enables faster time to therapy for patients.5
  • 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 with no delay. This also enables faster time to therapy for patients.5 Approximately 56 percent of PAs are thus avoided.6
  1. Cigna Book of Business national study 2017. Projection compares health care spend for medical service categories including: Drugs and Biologics, Inpatient Facility, Outpatient Facility, Professional Services, Other Medical Services. 
  2. Savings projection based on national book of business results for clients with full drug utilization management program, 2016. Savings are not guaranteed and individual client results will vary.
  3. Savings projection based on national book of business results for clients with full drug utilization management program, 2016. Savings are not guaranteed and individual client results will vary.
  4. Cigna National Book of Business analysis of step therapy activity, October 2018 – performance dependent on therapeutic class – subject to change.
  5. Cigna National Book of Business analysis of ePA program, full-year 2018.
  6. Based on most recent results of Cigna Rx Claims Connect, reported May 2019.

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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 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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