Strong Utilization Management checkpoints help improve outcomes and save

At Cigna, we want to help customers receive safe, cost-effective treatments. To reach this crucial goal, we maintain a detailed path of utilization management (UM) checkpoints that we apply to all medication claims, especially those for specialty medications. As a result, we manage utilization and spend of these high-touch and often high-cost therapies. We work with providers to help ensure they prescribe the most clinically and cost-effective treatments for their Cigna patients. “We have a very robust utilization management (UM) program that helps ensure that the right patients get the right drug for their condition for the right amount of time,” explained Mark Johnson, pharmacy sales product director for Cigna Pharmacy.”

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.

Prior authorization (PA) works to compare prescribed purpose to indicated use.
PA helps ensure that medications are prescribed according to indications approved by the U.S. Food and Drug Administration and supported evidence for appropriateness of use. A prospective review confirms if the prescribed medication meets FDA-approved indications.

Our three key areas of focus in managing any specialty treatment:
  1. Utilization
  2. Coordination of drug administration
  3. Management of associated costs

The PA process drives use of preferred medications, including biosimilar products that help reduce the cost of expensive specialty drugs for customers. When we look at a claim for a drug for customers who have Cigna integrated benefits, we can easily assess their treatment history and health needs to make a swift coverage decision. This is because we can see both their medical and pharmacy benefit claim history.

Quantity limits (QL) help ensure clinically appropriate dosing and duration of use to mitigate waste and potential stockpiling of medication.
A QL triggers through Cigna Pharmacy Management's online, point-of-sale concurrent drug utilization review. A QL will apply for specific medications on a per-prescription, day, month, period, or lifetime basis - depending on the medication. Our work to monitor use of opioids is one way we put QL to work. It’s an important part of our commitment to fight against opioid misuse and overdose. 

Clients also have a choice when setting home-delivery day’s supply limits for specialty drugs: 30-days, 90-days, or Clinical Day’s Supply - which uses smart logic to manage waste and promote medication adherence for costly specialty drugs.

Step therapy (ST) helps ensure use of clinically effective first-line medications before second-line coverage is considered.
Many individuals may not know an alternative, lower-cost medication is even an option. By proactively bringing such alternatives to the attention of customers and their providers, ST can help customers access lower-cost preferred brand or generic medications with little to no disruption.

Integrated benefits with Cigna help ensure optimal UM reviews 
Cigna provides total cost management. We apply traditional pharmacy benefit management principles consistently across both the pharmacy and medical benefit. Clients can select from three comprehensive UM packages available at no added cost:

  • The Essential Protection package is recommended for all clients. This package delivers an estimated $3-$4 per member per month (PMPM) pharmacy savings1 and 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 delivers an estimated $3.50-$5 PMPM pharmacy savings.1 This package is for clients seeking maximum clinical oversight and affordability. It offers the same protection as the Essential package, plus additional ST and PA edits

We help make UM easier for customers and health care providers through:

  • 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 70 percent of people move to the alternative medication when we provide clinical and cost information to doctors.2
  • 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.3
  • 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.4 Approximately 56 percent of PAs are thus avoided.4

Cigna's UM offering is available at no additional cost to clients. Talk to your Cigna representative to learn more.

  1. Savings projection based on national book of business results for clients with full drug utilization management program, 2019. Savings are not guaranteed and individual client results will vary.
  2. Cigna National Book of Business analysis of step therapy activity, October 2018 – performance dependent on therapeutic class – subject to change.
  3. Cigna National Book of Business analysis of ePA program, full-year 2018.
  4. Based on most recent results of Cigna Rx Claims Connect, reported May 2019.

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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, review your plan documents or contact a Cigna representative.

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