CurrentCignaPolicy CNF002

Non-Preferred Drug Coverage Review - (Formulary Exception Criteria) - (CNF002)

Defines Cigna's approach for medical necessity review and approval of non-formulary / non-preferred prescription drugs via Product Specific Exception Criteria. Governs documentation, required trials, approval duration, and applicability across Cigna Companies and benefit plans.

Policy Summary

PayerCigna

PolicyNon-Preferred Drug Coverage Review - (Formulary Exception Criteria) - (CNF002)

Policy CodePolicy CNF002

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriber must request a Product Specific Exception and submit required documentation when specified; ensure claims use the appropriate covered diagnosis/procedure codes to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

12 monthsDefault Approval Duration

Coverage Summary

Policy Title: Non-Preferred Drug Coverage Review (Formulary Exception Criteria); Policy Number: CNF002. Status: CURRENT.

Scope: This policy defines Cigna's approach for medical necessity review and approval of non-formulary / non-preferred prescription drugs via Product Specific Exception Criteria, and governs required documentation, prior trials, approval duration, and applicability across Cigna Companies and benefit plans.

Applicability and precedence: The Coverage Policy applies to health benefit plans administered by Cigna Companies. However, a customer's specific benefit plan document (for example, Group Service Agreement, Evidence of Coverage, Certificate of Coverage, or Summary Plan Description) or controlling federal/state law supersedes this Coverage Policy where there is a conflict. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

Medical-Necessity Criteria

General Exception Approval Criteria

Cigna covers non-preferred products as medically necessary when the Product Specific Exception Criteria are met:

Requested product is listed on the Non-Preferred Drug Coverage Review (Formulary Exception Criteria) List and has Product Specific Exception Criteria.
Prescriber provides required documentation supporting trials of other agents when criteria note '[documentation required]'.
Documentation may include chart notes, prescription claims records, and/or prescription receipts.
Coverage determinations consider the terms of the applicable benefit plan, applicable laws/regulations, collateral materials including Coverage Policies, and clinical judgment by medical directors.
When coverage does not depend on specific circumstances, reimbursement provided only if submitted with relevant covered diagnosis and/or procedure codes; claims without covered codes will be denied as not covered.

Approval Duration

Approval duration is 12 months unless otherwise noted.

Default Exclusion

Not Medically Necessary / Default Exclusion: Any other exception not meeting Product Specific Exception Criteria is considered not medically necessary.

Provider Actions

Prior Authorization

Formulary Exception / Medical Necessity Review Required

Prescriber must request a Product Specific Exception based on the listed Exception Criteria. Approval requires that the request meet those Product Specific Exception Criteria and that any required documentation specified in the criteria be submitted.

Documentation Required

Documentation of Prior Trials

When criteria indicate '[documentation required]', the prescriber must provide written documentation supporting trials of other agents. Acceptable documentation may include chart notes, prescription claims records, and prescription receipts.

Billing Rule

Use Appropriate Diagnosis/Procedure Codes

Submit claims using the most appropriate covered diagnosis and/or procedure codes as of the date of service. Claims submitted without covered codes under the applicable Coverage Policy will be denied as not covered.

Background

This Coverage Policy provides guidance for interpreting standard benefit plans administered by Cigna Companies regarding prescription drugs that are not covered on the Cigna National Formulary unless approved through a medical necessity review. It explains that certain products are not covered by the formulary unless approved and that Cigna covers these products as medically necessary when the Product Specific Exception Criteria are met.

Coverage determinations require consideration of the terms of the applicable benefit plan document in effect on the date of service, any applicable laws and regulations, relevant collateral materials including Coverage Policies, and the specific facts of the situation. Medical directors exercise clinical judgment and have discretion in individual coverage determinations.

When criteria indicate that documentation is required, the prescriber must provide written documentation supporting trials of other agents (for example, chart notes, prescription claims records, and/or prescription receipts). Documentation requirements and criteria for specific non-preferred products are listed on the Non-Preferred Drug Coverage Review (Formulary Exception Criteria) List and will be updated as new published data become available.

Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if services are submitted in accordance with the relevant Coverage Policy criteria, including covered diagnosis and/or procedure codes. Providers must use the most appropriate codes as of the effective date of submission; claims submitted without covered codes under the applicable Coverage Policy will be denied as not covered. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

Product Specific Exception Criteria: the detailed medical necessity criteria listed for each non-preferred product on the Non-Preferred Drug Coverage Review (Formulary Exception Criteria) List that must be met for coverage.