CurrentCignaPolicy N/A

Epinephrine Auto-Injectors Step Therapy Policy

Defines Cigna's step therapy requirements for coverage of epinephrine auto-injectors (EpiPen generics and branded EpiPen) for members, specifying Step 1 preferred products and criteria for approving Step 2 products.

Policy Summary

PayerCigna

PolicyEpinephrine Auto-Injectors Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial revision (targeting and Step 2 adjustments)

Effective Date

Next Review DateFeb 4, 2026

Key ActionObtain documentation that the patient tried one Step 1 generic epinephrine auto-injector before requesting approval for a Step 2 product (approvals are provided for 1 year).

SourceLink

POLICY UPDATE CHANGES

Auvi-Q auto-injectors were removed from Step 2 and are no longer targeted in the policy; exceptions for Auvi-Q were removed.

Adrenaclick (brand) was removed from the note outlining which products are not targeted in this policy.

2Step levels

1 yrApproval duration

≥30 kg / 15–30 kgDosing thresholds

EpiPen genericsPreferred Step 1

Coverage Criteria

Policy Summary

PayerCigna

PolicyEpinephrine Auto-Injectors Step Therapy Policy

Policy CodePolicy N/A

Change TypeMaterial revision (targeting and Step 2 adjustments)

Effective Date

Next Review DateFeb 4, 2026

Key ActionObtain documentation that the patient tried one Step 1 generic epinephrine auto-injector before requesting approval for a Step 2 product (approvals are provided for 1 year).

SourceLink

On This Page

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Step Therapy Criteria

Covered when ALL of the following are met

Step therapy approval logic: Patient has tried one Step 1 product (generic epinephrine auto-injector 0.15 mg or 0.3 mg).1 prior Step 1 trial

If met, approve Step 2 product (EpiPen 0.15 mg or EpiPen Jr. 0.3 mg). All approvals are provided for 1 year in duration.

This policy does not target certain epinephrine products. Specifically, Auvi-Q, Symjepi, and the authorized generic to Adrenaclick (brand discontinued) are not targeted in this policy.

Use of any epinephrine auto-injector that does not meet the policy's step therapy criteria is considered not medically necessary.

Provider Actions and Billing

Step Therapy

Step therapy requirement

This program requires a Step Therapy trial before coverage of Step 2 epinephrine auto-injectors. If the Step Therapy rule is not met at point of service, coverage will be determined by the Step Therapy criteria. All approvals are provided for 1 year.

Step 1 products: epinephrine auto-injector 0.15 mg and 0.3 mg (generic to EpiPen/EpiPen Jr.)
Step 2 products: EpiPen 0.15 mg and EpiPen Jr. 0.3 mg
All approvals valid for 12 months
Auvi-Q, Symjepi, and the authorized generic to Adrenaclick (brand discontinued) are not targeted by this policy

Step Therapy

Step therapy sequence

Providers must document trial of one Step 1 product before a Step 2 product will be approved. If the patient has tried one Step 1 product, approve a Step 2 product per criteria.

Requirement: trial of one Step 1 product prior to Step 2 approval
Approval duration: 1 year

Billing Rule

Coding and submission

Providers must submit claims using the most appropriate and current diagnosis and procedure codes as of the date of submission. Claims lacking covered diagnosis/procedure codes under the applicable coverage policy will be denied as not covered.

Use most appropriate codes as of the submission effective date
Claims without covered code(s) will be denied as not covered

Denial Risk

Billing code compliance

Reimbursement is not allowed for services billed for conditions or diagnoses that are not covered under this coverage policy. Providers should confirm covered codes and rationale when submitting prior authorization requests or claims to avoid denials.

Confirm covered diagnosis/procedure codes before billing
Ensure prior authorization requests include documentation of Step 1 trial when requesting Step 2 coverage

Definitions and Dosing

inv-11: Epi auto-injector dosing recommendations

Recommended dose for patients ≥ 30 kg0.3 mg (administer via EpiPen or generic equivalent)

Recommended dose for patients 15–30 kg0.15 mg (administer via EpiPen Jr. or generic equivalent)

Dosing consistencyAll epinephrine auto-injectors are administered and dosed similarly

inv-12: Targeted products

Step 1 (targeted)EpiPen generics and EpiPen Jr. generics (preferred initial products)

Step 2 (targeted)Branded EpiPen products (EpiPen 0.15 mg and EpiPen Jr. 0.3 mg) require prior trial of one Step 1 product

Not targeted / excludedAuvi-Q, Symjepi, and the authorized generic to Adrenaclick are not targeted in this policy

Policy sequencing noteThis program encourages use of a Step 1 product prior to Step 2; approvals for Step 2 are provided for 1 year

Requirement	Details
Trial prior to Step 2	Patient must have tried one Step 1 product (epinephrine auto-injector 0.15 mg or 0.3 mg; generic to EpiPen/EpiPen Jr.) before a Step 2 product (EpiPen 0.15 mg or EpiPen Jr. 0.3 mg) will be approved.
Approval duration	All approvals are provided for 1 year in duration.
Policy scope note	Auvi-Q, Symjepi, and the authorized generic to Adrenaclick are not targeted in this policy.

OpenPayer

Epinephrine Auto-Injectors Step Therapy Policy

Coverage Criteria

Coding and Dosing

Provider Actions and Billing

Background

Definitions and Dosing

Initial Therapy (Step 1)

Step Therapy Requirements