eviCore helps bring treatment clarity for customers facing cancer

In 2021, there will be an estimated 1.9 million new cancer cases diagnosed and 608,570 cancer deaths in the United States.1 While new drugs and therapies bring fresh hope for those with a cancer diagnosis, they also mean a growing sea of decisions for customers and health care providers to make. Contributing an extra dose of expertise to assist this process, eviCore helps confirm the best course of care.

Our national integrated oncology management program through eviCore helps customers sort through their cancer treatment choices.
The eviCore team of cancer professionals consists of board certified physicians, nurses, pharmacists, and genetic counselors. Together, they perform an upfront prior authorization (PA) review of a customer’s entire oncology treatment regimen. The review spans across treatments like infused chemotherapy and oral oncolytic and supportive cancer drugs, whether covered under the pharmacy or medical benefits. This process works alongside our radiology and radiation therapy precertification programs. After performing their thorough review, the eviCore team gives one, blanket approval.

To perform their review process, the eviCore team consults intuitive clinical decision support software. They engage in peer-to-peer consultations. They also apply continually updated evidence-based clinical policies, endorsed by the National Comprehensive Care Network (NCCN) – a not-for-profit alliance of 31 leading cancer centers.2

The eviCore review process benefits customers in many ways:

  • It’s fast and direct. Within a two-day review timeframe, the eviCore team communicates PA approval and revisions directly to the customer, as well as to requesting and rendering providers.
  • Health care providers are better equipped to choose the right tests and treatments for each unique patient. The eviCore team identifies under and over utilization of cancer support therapies, helps identify more clinically optimal therapies, and redirects to the most appropriate site of care for medication administration.
  • Customers are less likely to experience avoidable side effects from medication interactions that could have otherwise landed them in the emergency room (ER) or hospital.
  • Customers may experience improved clinical outcomes if eviCore identifies opportunities for earlier and improved care coordination. This could include making proactive referrals to Cigna’s oncology case management team.
  • Lower total medical spend can result when customers experience better clinical outcomes.

The eviCore review process is part of our integrated approach, which helps yield savings.
The higher customer engagement achieved as a result of integrated medical and pharmacy benefits helps lead to lower costs, in particular, for those with costly conditions. For oncology patients, we’ve seen savings of $11,679 per member per year (PMPY) and 24% lower inpatient costs.3

With our integrated benefits and collaborative clinical teams, our customers and clients facing cancer diagnosis receive a cradle of support to handle what can be a stressful and overwhelming experience. This support comes in the form of a dedicated case management team that specializes in oncology, specialty care managers, social workers, pharmacists, and behavioral clinicians. The eviCore review process complements this support.

In 2020, cancers of the breast, lung and colon/rectum were the most common, in terms of new cases diagnosed.4 For a breast cancer patient, for example, at the beginning of her cancer journey, eviCore plays an early role to review and approve the breast magnetic resonance imaging (MRI) test her doctor orders. Later in her journey, after a confirmed diagnosis and lumpectomy surgery, when looking to begin a chemotherapy regimen, eviCore works to review and approve the customer’s treatment forecast.

“Treating a customer with cancer crosses benefits. In fact, there are several oral drugs being approved for cancer care right now, and they are often combined with infusion therapies covered on the medical benefit,” said Dr. Bhuvana Sagar, a national medical executive here at Cigna, and our leading expert on oncology. “Having integrated benefits helps us manage the entire course of therapy better, offer alternative pathway options and look at the entire regimen with a holistic view.”

Following eviCore’s approval of a customer’s chemotherapy regimen, eviCore then seamlessly passes the authorization data to Accredo®, our Cigna specialty pharmacy. From there, an Accredo Oncology Therapeutic Resource Center® (TRC) team further supports the customer and her oncologist with a broad range of services to help position them both for success.

LEARN MORE

  1. Cancer Facts & Figures 2021. American Cancer Society. www.cancer.org. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.html. Accessed May 11, 2021.
  2. National Comprehensive Cancer Network. Member Institutions. www.nccn.org. https://www.nccn.org/home/member-institutions. Accessed June 14, 2021.
  3. Cigna 2020 Book of Business study of medical customers with integrated medical, pharmacy and total behavioral health vs. those with Cigna medical and carved out pharmacy. Individual results will vary; not guaranteed. Average annual per member per year (PMPY) and per patient per year (PPPY).
  4. Cancer. World Health Organization. www.who.int. 3 March 2021. https://www.who.int/news-room/fact-sheets/detail/cancer.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including eviCore healthcare MSI, LLC (d/b/a/ eviCore healthcare), Express Scripts, Inc., Accredo Health Group, Inc., or their affiliates. “Accredo” is a trademark of Express Scripts Strategic Development, Inc.

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