CurrentCignaPolicy IP0352

LymePak (doxycycline hyclate tablets) coverage criteria

This policy governs coverage criteria for LymePak (doxycycline hyclate tablets) for treatment of early Lyme disease for members of Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyLymePak (doxycycline hyclate tablets) coverage criteria

Policy CodePolicy IP0352

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

Key ActionObtain prior authorization and document inability to obtain BOTH doxycycline hyclate capsules and tablets when requesting LymePak.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>= 8minimum patient age for coverage

>= 45 kgminimum patient weight for coverage

one cycleauthorization duration

4/1/2024policy effective date

Coverage Criteria

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

LymePak coverage criteria

Patient eligibility
- A. Age: 8 years and olderAge >= 8 years
- B. Weight: 45 kg (99 lb) and aboveWeight >= 45 kg (99 lb)
C. Preferred product criteria are met: documentation of an inability to obtain BOTH doxycycline hyclate capsules and doxycycline hyclate tablets (not supplied as a dose pack).
Documentation must be provided when requesting LymePak.

Policy Summary

PayerCigna

PolicyLymePak (doxycycline hyclate tablets) coverage criteria

Policy CodePolicy IP0352

Change TypeNo material change

Effective DateApr 1, 2024

Next Review Date

Key ActionObtain prior authorization and document inability to obtain BOTH doxycycline hyclate capsules and tablets when requesting LymePak.

SourceLink

On This Page

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.

Initial approval duration: one cycle of therapy; reauthorization not applicable.

Prior authorization is required.

Operational notes: Receipt of sample product does not satisfy any criteria requirements for coverage.

Any use other than treatment of early Lyme disease (erythema migrans attributable to Borrelia burgdorferi) is considered experimental, investigational, or unproven and is excluded from coverage.

Coding and Eligibility Thresholds

inv-03: Minimum age — 8 years

Minimum age for coverage8 years

Age requirement sourcePolicy criteria: 'Age 8 years and older' from Medical Necessity Criteria

Clinical indication age noteLymePak indicated for adults and pediatric individuals 8 years of age and older

inv-04: Minimum weight — 45 kg (99 lb)

Minimum weight for coverage45 kg (99 lb)

Weight requirement sourcePolicy criteria: 'Weight 45 kg (99 lb) and above' from Medical Necessity Criteria

Clinical indication weight noteLymePak indicated for individuals weighing 45 kg and above

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization and Duration

Prior authorization is required. Initial approval duration is a single cycle of therapy.

Initial approval duration: one cycle of therapy
Reauthorization: not applicable

Documentation Required

Failure of or Inability to Obtain Standard Doxycycline Formulations

Coverage requires documentation that the prescriber or pharmacy was unable to obtain BOTH doxycycline hyclate capsules and doxycycline hyclate tablets (not supplied as a dose pack) prior to approval of LymePak (doxycycline hyclate tablets).

Documentation must show attempts to obtain doxycycline hyclate capsules AND standard doxycycline hyclate tablets (not dose pack).
Receipt of sample product does not satisfy documentation requirements.

Documentation Required

Required Clinical and Supply Documentation

Documentation must confirm the diagnosis of erythema migrans due to Borrelia burgdorferi and that the patient meets age and weight eligibility. Also include records of supply/inventory attempts showing inability to obtain standard doxycycline formulations.

Diagnosis: Erythema migrans due to Borrelia burgdorferi
Age: 8 years and older
Weight: 45 kg (99 lb) and above
Documented attempts to obtain doxycycline hyclate capsules and doxycycline hyclate tablets (not dose pack)
Note: Receipt of sample product does not meet supply documentation requirements

Denial Risk

Non‑Covered Uses

Use of LymePak for any indication other than treatment of early Lyme disease (erythema migrans due to Borrelia burgdorferi in eligible patients) is excluded and considered experimental, investigational, or unproven.

Non-covered: Any indication other than early Lyme disease (erythema migrans due to Borrelia burgdorferi in patients meeting age and weight criteria)

Background

Doxycycline is a broad‑spectrum oral antibiotic used for prevention and treatment of Lyme disease caused by Borrelia burgdorferi. Clinical guidance and the product’s indication support use of doxycycline for post‑tick‑bite prophylaxis and for treatment of erythema migrans (early Lyme disease). LymePak (doxycycline hyclate tablets) specifically addresses treatment of early Lyme disease in patients meeting the policy’s eligibility criteria, including a minimum age of 8 years and minimum weight of 45 kg (99 lb).

Definitions

inv-10: Early Lyme Disease (erythema migrans) — Clinical diagnosis evidenced by erythema migrans attributable to Borrelia burgdorferi

DefinitionClinical diagnosis evidenced by erythema migrans attributable to Borrelia burgdorferi

Policy citation'Early Lyme Disease as evidenced by erythema migrans due to Borrelia burgdorferi' (Medical Necessity Criteria)

Indication linkageThis definition is the required diagnosis for LymePak coverage