Oncology Medications
Defines medical necessity, preferred product criteria, and drug-specific coverage rules for oncology medications administered under Cigna health benefit plans; applies to providers requesting coverage for cancer drugs and biologics.
Fruzaqla Appendiceal, Colon or Rectal Cancer: Added preferred product step requirement through Lonsurf for Employer Plans.
Krazati: Added has brain metastases exception to the sotorasib (Lumakras) preferred product step requirement.
Multiple preferred product step requirements and exceptions updated across Employer, Individual and Family, and Pathwell Specialty Drug List plans (examples include Abraxane, Paclitaxel albumin-bound, Alunbrig/Zykadia, Votrient, Braftovi, Mektovi, Bosulif, Scemblix, Tasigna).
Docivyx preferred product criteria requirement for Employer Plans and Individual and Family Plans added.
Keytruda preferred product criteria requirement added for Cigna Pathwell Specialty Drug List Plans (and subsequently changed to Employer and Individual and Family Plans in later revisions).
Added 'All Other Conditions. Approve [drug] if the patient meets the Oncology Medications criteria above the table' for multiple drugs (e.g., Braftovi, Fruzaqla, Keytruda, Opdivo, Tecentriq).
Changed Herceptin Hylecta requirement to allow 'Trial of, contraindication, or intolerance to ONE of the following' biosimilars and clarified inability to obtain/maintain intravenous access wording.
For Ibrance, premenopausal patients using in combination with fulvestrant as subsequent therapy require prior trial of Verzenio.
Scemblix exception changed: requirement reduced from two prior TKIs to at least one other tyrosine kinase inhibitor for CML.
Khapzory requirement changed to require trial of one generic levoleucovorin or generic leucovorin injection; if already started on Khapzory, patient must have tried generic levoleucovorin.
Talzenna criteria updated to clarify BRCA-mutated prostate cancer requirements and to address patients with non-BRCA homologous recombination repair mutations.
Multiple drugs (e.g., Mektovi, Krazati, Tasigna, Onivyde, Provenge, Paclitaxel albumin-bound) were updated with an 'All Other Conditions' approval pathway referencing Oncology Medications criteria.
Added criteria for Danziten, Imkeldi, Hercessi, Ziihera, Ivra, Tepylute and others across plan types.
Removed 'Philadelphia Chromosome Positive' language from several drug criteria (Bosulif, Danziten, Iclusig, Scemblix, Tasigna).
Onivyde pancreatic adenocarcinoma criteria changed: removed requirement for prior fluoropyrimidine-based therapy without irinotecan; added ECOG 0-1 and alternatives for prior regimens; added ampullary adenocarcinoma as a new condition.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.