CurrentCignaPolicy N/A

Serious Mental Illness Step Therapy Exception Form

A provider-completed exception request form to request exemption from step-therapy requirements for prescription drugs for patients with serious mental illness. Collects patient, insurance, prescriber, medication, diagnosis, and attestation information to support an exception under Colorado statute § 10-16-145.

Policy Summary

PayerCigna

PolicySerious Mental Illness Step Therapy Exception Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective Date

Next Review Date

Key ActionComplete and sign the exception form, attest which statutory criterion applies, and handle protected health information per privacy rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes; this is an administrative form to request step-therapy exceptions.

1Form purpose

4Attestation criteria listed

Policy overview

This is a provider-completed exception request form used by Cigna to collect the necessary patient, insurance, prescriber, medication, diagnosis, and attestation information to evaluate exemptions from prescription drug step-therapy requirements for patients with serious mental illness. The form is titled Serious Mental Illness Step Therapy Exception Form and is marked CURRENT.

The form is used to support requests made under Colorado statute § 10-16-145. Providers must complete applicable sections and sign or electronically verify the attestation so the payer (Cigna) can evaluate the request in accordance with the referenced statute.

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Attestation criteria for step-therapy exception

Provider must attest that at least one of the following statutory criteria is met:

ANY of the following

The required prescription drug is contraindicated or will likely cause an adverse reaction or harm to the covered person.
The required prescription drug is ineffective based on the known clinical characteristics of the covered person and the known characteristics of the prescription drug regimen.
The required prescription drug or another prescription drug in the same pharmacologic class or with the same mechanism of action was previously used by the covered person and was discontinued due to lack of efficacy/effectiveness, diminished effect, or an adverse event.
The prescribing provider selected the requested drug for the medical condition after the covered person underwent step therapy or after having sought and received a step-therapy exception.

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ref": "b1_0"

title": "Attestation criteria for step-therapy exception"

Required provider actions and documentation

Documentation Required

Complete and sign exception form

Fill out all applicable sections of the exception form and sign or electronically verify the attestation and signature date to request a step-therapy exception.

Patient
Insurance
Prescriber
Medication
Diagnosis
Attestation
Signature date

Prior Authorization

Step-therapy exception request submission

Submitting this completed form constitutes a request for exemption from step-therapy requirements; the provider must attest which statutory criterion under § 10-16-145 applies to the patient.

Documentation Required

Protected health information handling

This form contains Protected Health Information and must be handled and transmitted in accordance with HIPAA and the included confidentiality notice.

Follow applicable privacy rules (HIPAA).
Secure transmission and restrict access to intended recipients.
Comply with the confidentiality notice on the form.

OpenPayer

Serious Mental Illness Step Therapy Exception Form

Policy overview

Attestation criteria for step-therapy exception

Required provider actions and documentation

Scope and definitions

Revision history