CurrentCignaPolicy N/A

Diuretics -Loop Products Step Therapy Policy

Policy Summary

PayerCigna

PolicyDiuretics -Loop Products Step Therapy Policy

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review DateJun 18, 2025

Key ActionDocument that the patient has tried one Step 1 product before approving a Step 2 product; approvals are provided for 1 year when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Annual Revision indicated 'No criteria changes' for reviews dated 06/14/2023, 06/26/2024, and 06/18/2025.

4Step 1 products listed

4Step 2 products listed

1 yrApproval duration

Coverage Summary

Defines a step therapy program for selected loop diuretics administered under Cigna benefit plans, specifying Step 1 preferred products and Step 2 products that require prior trial of a Step 1 product for coverage; approvals are for 1 year. Coverage stance: covered_with_criteria — Step 2 products are covered when step therapy criteria are met (patient has tried one Step 1 product).

Step Therapy Criteria

Diuretics -Loop Products Step Therapy Policy product(s) is(are) covered as medically necessary when the following step therapy criteria is(are) met. Any other exception is considered not medically necessary.

Step 1 trial requirement: Patient has tried one Step 1 Product
If the patient has tried one Step 1 Product, approve a Step 2 Product.

Step 1 Products (preferred): Step 1: bumetanide tablets, ethacrynic acid tablets, furosemide tablets, torsemide tablets

Step 1 products are preferred prior to Step 2 products.

Applicable Products / Codes

Step 1 Products (preferred)mixedCovered

	bumetanide tablets (generic only)
	ethacrynic acid tablets (Edecrin ® - Bausch/Patheon, generic)
	furosemide tablets (Lasix ® - Validus, generic)
	torsemide tablets (Soaanz ® - Sarfez, generic torsemide)

Step 2 Products (require Step 1 trial)mixedCovered

	Edecrin tablets (ethacrynic acid tablets - Bausch/Patheon, generic listed also in Step 1)
	Lasix tablets (furosemide tablets - Validus, generic listed also in Step 1)
	Soaanz tablets (torsemide tablets - Sarfez)
	Furoscix (furosemide subcutaneous injection by on-body infusor - scPharmaceuticals)

Provider Actions & Prior Authorization

Prior Authorization

Step therapy requirement for Step 2 products

Coverage of Step 2 products requires documentation that the patient has tried one Step 1 product; approvals, when criteria are met, are provided for 1 year.

Documentation Required

Documentation of Step 1 trial

Provider must document that the patient has tried one Step 1 product before approving a Step 2 product (clinical records should support prior trial).

Background

The policy covers loop diuretics indicated for treatment of edema associated with congestive heart failure, hepatic and renal disease, and for treatment of hypertension for some agents. The program encourages use of Step 1 products (bumetanide tablets, ethacrynic acid tablets, furosemide tablets, torsemide tablets) before Step 2 products.

Brief statistics

Step 1 products listed4

Step 2 products listed4

Approval duration1 year

Revision History

06/14/2023annual_review

Annual Revision indicated 'No criteria changes'.

06/26/2024annual_review

Annual Revision indicated 'No criteria changes'.

06/18/2025annual_reviewLatest

Annual Revision indicated 'No criteria changes'.

Policy Summary

PayerCigna

PolicyDiuretics -Loop Products Step Therapy Policy

Policy CodePolicy N/A

Change Typeclarified

Effective Date

Next Review DateJun 18, 2025

Key ActionDocument that the patient has tried one Step 1 product before approving a Step 2 product; approvals are provided for 1 year when criteria are met.

SourceLink

On This Page

OpenPayer

Diuretics -Loop Products Step Therapy Policy

Coverage Summary

Applicable Products / Codes

Provider Actions & Prior Authorization

Clinical Evidence & Prescribing References

Background

Revision History