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:
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:
We help make UM easier for customers and health care providers through:
Cigna's UM offering is available at no additional cost to clients. Talk to your Cigna representative to learn more.
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.
All Cigna products and service 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., Evernorth, 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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