Pharmacy and Medical Prior Authorization
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Defines medical necessity review and prior authorization requirements for drugs requiring pharmacy or medical prior authorization for Cigna-administered Employer Group and Individual and Family Plans, including non-formulary drug exception criteria.
Added Individual and Family Plan product-specific medical necessity criteria for multiple products including Nuzyra, Tonmya, Corphena, brivaracetam oral solution and tablets, and many others with various effective dates.
Updated Individual and Family Plan product-specific medical necessity criteria for numerous products such as econazole nitrate foam, Aptiom, Fycompa, Xdemvy, topiramate extended-release capsules, and many more.
Removed Individual and Family Plan product-specific medical necessity criteria for several products including Nuzyra (at times), Tonmya, Spritam, and others as listed.
Added preferred product requirement criteria for a set of products effective 8/15/2026 and other dates, including Auvelity Titration Pack, Bysanti, and many generics/brands.
Updated preferred product requirement criteria for numerous products with effective dates (examples include azilsartan tablets, Auvelity, Motegrity, Trulance).
Coverage and Medical Necessity Criteria
General prior authorization medical necessity criteria
Drugs requiring prior authorization are considered medically necessary when BOTH of the following are met:
Overall
- Requirement 1: ONE of the following: A) Use is approved and listed in the FDA product information (Label) and the dosage, frequency, site of administration, and duration of therapy is not contraindicated or otherwise not recommended in the Label; OR B) Use is supported according to standard medical reference compendia (for example, Clinical Pharmacology, Micromedex, Wolters Kluwer Facts and Comparisons) and is not contraindicated or otherwise not recommended in the FDA product information (Label).
- Requirement 2: Where available, trial of therapeutic alternatives is required unless clinically inappropriate; prior use of all formulary or covered alternatives meets this requirement unless more than five alternatives exist (five is the maximum required).max 5 alternatives
Individual and Family Plan non-formulary drugs are considered medically necessary only when the product-specific criteria in the linked IFP spreadsheet are met. Refer to the IFP product-specific medical necessity criteria: Drugs Requiring Medical Necessity Review for Individual and Family Plans (linked spreadsheet). Any other non‑formulary exception or use not meeting those product‑specific criteria is considered not medically necessary. Documentation is required where noted in the product criteria and must include patient‑specific identifying information.
Unless a use meets the policy’s stated medical necessity requirements, it is considered not medically necessary. Criteria will be updated as new published data are available. Providers should follow the product‑specific criteria and submit required documentation when indicated; absent those criteria and documentation, coverage is not provided.
Provider Actions, Prior Authorization, and Documentation
Prior authorization medical necessity — meet both FDA/compendia and alternative‑trial requirements
Drugs that require pharmacy or medical prior authorization must meet medical necessity before approval: (1) the use must be FDA‑approved and consistent with the Label or supported by standard medical compendia and not contraindicated, and (2) where available, therapeutic alternatives must be tried unless clinically inappropriate (maximum five alternatives). Approval durations may be up to 12 months. Submit prior authorization requests with supporting clinical information aligned to these requirements.
- Requirement 1: FDA Label or standard compendia support (see policy statement).
- Requirement 2: Trial of therapeutic alternatives unless clinically inappropriate (max 5).
- Approval duration: up to 12 months.
Product‑specific prior authorization required — follow listed criteria
Prior authorization is required for many listed products and formulations; providers must submit requests that follow the product‑specific medical necessity criteria documented in this policy (see Revision Details and individual product entries).
- Requests must follow the updated product‑specific criteria for each listed drug.
- See the Revision Details and Individual and Family Plan product lists for affected products and effective dates.
Follow updated product‑specific criteria and effective dates for prior authorization
Prior authorization determinations are governed by the updated product‑specific medical necessity criteria and any applicable preferred‑product requirements added or changed in this revision; submit requests aligned to the criteria and the effective dates noted for each product.
- Adhere to the product‑specific criteria and the effective dates in the Revision Details.
- IFP (Individual and Family Plan) product lists in the policy must be used where specified.
Therapeutic alternatives must be tried prior to approval (max 5)
Where available, prior authorization requires trial of therapeutic alternatives before approval; prior use of all formulary/covered alternatives meets the requirement unless more than five alternatives exist (five is the maximum required).
- Document prior trials of formulary or covered alternatives.
- Do not exceed requesting trials of more than five alternatives.
Step/titration (starter packs) — follow product entries for plan‑specific requirements
Several insulin, diabetes, and respiratory products reference plan‑specific step, titration, or starter‑pack criteria; prior authorization requests for these products must follow the updated product‑specific step/titration guidance in the individual product entries.
- Examples include Lamictal XR starter and Fanapt titration pack entries and multiple insulin starter/titration products listed across the Revision Details.
- Check individual product entries for plan‑specific titration/starter requirements.
Preferred‑product requirements may act as step requirements — use preferred products first
Preferred‑product requirement criteria were added or updated for multiple products and may operate as a step or preferred‑product requirement; providers should use preferred products when indicated before requesting non‑preferred agents.
- Revision Details list products with added/updated preferred product requirements (effective dates noted, e.g., 8/15/2026).
- Prior authorization for non‑preferred agents may be denied if preferred product requirements are not met.
Documentation required for entries marked '[documentation required]' — include patient‑specific evidence
When criteria include the notation '[documentation required]', submit the specified documentation with the prior authorization request; acceptable documentation may include chart notes, laboratory tests, medical test results, claims records, prescription receipts, and other patient‑identifying information.
- All documentation must include patient‑specific identifying information.
- Use the updated phrasing '[documentation required]' when checking criteria.
Updated documentation phrasing — '[documentation required]' and acceptable examples
Documentation phrasing in the criteria has been standardized to '[documentation required]'; acceptable examples include chart notes, labs, medical test results, claims records, prescription receipts, and other patient‑identifying information — include these when the product criteria require documentation.
- Ensure submissions labeled '[documentation required]' include one or more acceptable supporting documents.
- Updated documentation phrasing took effect per the Revision Details (see chunked dates).
IFP product‑specific criteria — adhere to listed criteria and effective dates
For Individual and Family Plan (IFP) members, follow the updated product‑specific medical necessity and preferred‑product requirement criteria as listed in the policy and observe the effective dates noted for each product.
- IFP non‑formulary drug exception criteria are maintained in the linked IFP spreadsheet.
- Providers must adhere to the product‑specific criteria and effective dates for IFP coverage determinations.
Billing codes: include covered diagnosis/procedure codes or claim will be denied
Claims submitted without covered diagnosis or procedure code(s) under the applicable Coverage Policy will be denied as not covered; use the most appropriate codes at time of submission.
- Verify covered diagnosis/procedure codes before claim submission.
- Claims billed for conditions not covered under the policy will be denied.
Missing required documentation may cause denial
Failure to include required documentation for criteria marked '[documentation required]' may lead to denial of medical necessity prior authorization requests.
- Confirm required documentation is attached when criteria specify '[documentation required]'.
- Missing documentation is an explicit denial risk called out in the Revision Details.
Noncompliance with updated product‑specific criteria risks denial
Noncompliance with updated product‑specific medical necessity or preferred‑product requirement criteria for listed drugs may result in prior authorization denial; ensure requests follow the current criteria and effective dates for each product.
- Review Revision Details for additions, updates, and removals and apply the criteria effective dates when submitting requests.
- Prior authorization requests that do not meet the updated criteria risk denial.
Definitions and Key Terms
Background and Eligibility
To be eligible for coverage under this policy a drug generally must be FDA‑approved for the requested use or supported by standard medical compendia, be prescribed by a licensed health care professional, and be purchased from a licensed pharmacy. Drugs requiring prior authorization must also meet the policy’s medical necessity requirements, including when applicable a trial of therapeutic alternatives (up to a maximum of 5 alternatives) unless clinically inappropriate. Documentation is required where noted in the criteria and must include patient‑specific identifying information.
Step Therapy and Titration / Preferred Product Tables
| Product / Reference | Step / Titration Reference |
|---|---|
| Lamictal XR starter | Policy revision notes reference plan-specific titration or starter pack criteria for Lamictal XR (starter pack) — prior authorization must follow the updated product-specific criteria. |
| Fanapt titration pack | Revision details list Fanapt titration pack; product-specific criteria may include titration pack requirements to be followed for prior authorization. |
| Insulin titration/starter products (e.g., Admelog, Apidra, Fiasp, Lyumjev, Novolin, Novolog Mix, insulin aspart protamine/aspart) | Multiple insulin products and starter/titration presentations are listed in the revision details; updated product-specific criteria may include plan-specific titration or starter pack guidance that must be followed for authorization. |
| Topiramate formulations (e.g., topiramate 50 mg oral sprinkle capsule, topiramate oral solution) | Revision entries add/update topiramate formulations and note product-specific medical necessity criteria which may reference titration or formulation-specific starter guidance. |
| NovoLog / insulin aspart (authorized generic) and Novolog Mix presentations | Revision details include NovoLog, insulin aspart (authorized generic), and Novolog Mix 70/30; product-specific criteria for these insulin products may include titration or starter pack references required for prior authorization. |
| Product / Reference | Preferred Product Requirement |
|---|---|
| Auvelity Titration Pack | Revision Details: Added preferred product requirement criteria effective 8/15/2026 for Auvelity Titration Pack — preferred product use may be required prior to coverage of non-preferred agents. |
| Bysanti (tablets and titration pack) | Revision Details: Added preferred product requirement criteria effective 8/15/2026 for Bysanti (tablets and titration pack); prior use of preferred products may be required before non-preferred coverage. |
| Qtern and umeclidinium/vilanterol inhalation powder (Anoro Ellipta authorized generic) | Revision Details: Removed IFP product-specific criteria for Qtern and umeclidinium/vilanterol (Anoro Ellipta authorized generic) and note an effective 8/1/2026 update; preferred-product entries in revision notes indicate preferred product requirement changes may apply per product entry. |
| Various listed products (azilsartan tablets, Auvelity, Motegrity, Trulance, etc.) | Revision Details indicate multiple added or updated preferred product requirement criteria (examples include azilsartan tablets and other products); where added, preferred product use may be required prior to coverage of non-preferred agents per the product-specific criteria. |
Revision Details and Policy Changes
Policy effective date set to 2026-08-15 including numerous product-specific additions, updates, and removals documented in the revision details.
Added multiple Individual and Family Plan product-specific medical necessity criteria effective 7/15/2026 (e.g., Pivya, levetiracetam ODT, Spritam-related entries and others).
Added Individual and Family Plan product-specific medical necessity criteria effective 7/1/2026 for various products including Allzital and several butalbital-containing formulations.
Updated and removed Individual and Family Plan product-specific medical necessity criteria effective 6/1/2026 (examples include updates to Aptiom, Briviact, eslicarbazepine acetate, Vowst; removals include selected branded products).
Added Individual and Family Plan product-specific medical necessity criteria for Nuzyra effective 5/1/2026 and listed related additions in the revision details.
Added Individual and Family Plan product-specific medical necessity criteria for dapagliflozin tablets and related SGLT2 products (listed) and numerous other additions noted in the 4/30/2026 revision details.
Removed Individual and Family Plan product-specific medical necessity criteria for Tonmya with an effective removal date noted as 4/15/2026.
Added Individual and Family Plan product-specific medical necessity criteria effective 3/1/2026 for products including Furoscix and Xhance as noted in the revision details.
Revision details include dated entries referenced 2/19/2026 in the revision lists for multiple products.
Revision details include updates with effective dates in late 2025 (examples include Firvanq and certain vancomycin oral formulations noted as 12/15/2025).
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