Topical Alpha Adrenergic Agonists
Defines Cigna's coverage stance for topical alpha-adrenergic agonists (brimonidine gel, Mirvaso, and oxymetazoline cream, Rhofade) when used to treat persistent facial erythema associated with rosacea in adults; applies to Cigna-administered health benefit plans and is subject to individual plan language and cosmetic benefit limits.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Covered Indications and Not Medically Necessary Conditions
Coverage and medical necessity stance for topical alpha-adrenergic agonists:
Indication per product labeling; coverage depends on applicable benefit plan language and cosmetic benefit provisions.
Receipt of sample product does not satisfy criteria requirements for coverage; benefit plan cosmetic exclusions may apply.
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