Cigna Coverage Criteria
Latest Cigna coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-15Percutaneous Electrical Nerve Field Stimulation (PENFS)Coverage of non-implantable PENFS for abdominal pain associated with irritable bowel syndrome or functional dyspepsia under Cigna-administered health benefit plans, subject to applicable plan documents and coverage criteria.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Alzheimer's Disease - Amyloid Beta- Directed Antibodies - KisunlaThis policy governs medical necessity, coding, and coverage criteria for Kisunla (donanemab-azbt) intravenous infusion for treatment of Alzheimer's disease for Cigna members. It affects providers seeking authorization and reimbursement for Kisunla.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Attention Deficit Hyperactivity Disorder Non-Stimulant MedicationsDefines Cigna prior authorization, medical necessity, and coverage criteria for non-stimulant ADHD medications Onyda XR (clonidine XR oral suspension) and Qelbree (viloxazine XR capsules) for members covered under Cigna benefit plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Clinical Trials — Routine Patient Care Costs/ServicesDefines coverage of routine patient care costs/services for qualified individuals participating in approved clinical trials under standard Cigna benefit plans, and lists related exclusions and coding. Applies to administration of Cigna plans where not superseded by the customer's benefit plan or applicable law.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Cysteamine (Oral) Products for Employer PlansThis policy governs prior authorization and coverage criteria for oral cysteamine products (specifically Procysbi) for treatment of nephropathic cystinosis for employer plans administered by Cigna, including documentation and prescriber specialty requirements.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Dermatology - Vtama Drug Quantity Management Policy - Per DaysDefines quantity limits and exception criteria for coverage of Vtama topical cream for Cigna-administered health benefit plans, affecting prescribers and pharmacy prior authorization processes.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Fixed Wing Air Ambulance TransportThis policy governs medical necessity and coding for fixed wing (conventional) air ambulance transport services for Cigna-administered health benefit plans and affects providers requesting coverage or reimbursement for such transports.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Glaucoma ProstaglandinsDefines prior authorization and medical necessity criteria for coverage of ophthalmic prostaglandin products to reduce intraocular pressure in patients with open-angle glaucoma or ocular hypertension for Cigna-administered health benefit plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Gynecomastia SurgeryThis policy governs coverage determinations for mastectomy, reduction mammoplasty, and liposuction (including ultrasonic-assisted) when used to treat gynecomastia for members of Cigna-administered health benefit plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Hereditary Angioedema - EkterlyThis policy governs prior authorization and coverage criteria for Ekterly (sebetralstat tablets) for treatment of acute hereditary angioedema (HAE) attacks in members of Cigna-administered health plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Imbruvica for Non-Oncology UsesDefines Cigna's prior authorization and medical necessity criteria for coverage of Imbruvica when used for non-oncology indications, primarily chronic graft-versus-host disease, and applies to Cigna-administered health benefit plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15KygevviThis policy governs prior authorization and medical necessity criteria for coverage of Kygevvi for treatment of thymidine kinase 2 deficiency (TK2d) under Cigna-administered health benefit plans. It affects prescribers and payers evaluating requests for Kygevvi.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Lumizyme (alglucosidase alfa) — Pompe Disease (acid alpha‑glucosidase deficiency)Defines Cigna's prior authorization, documentation, and clinical criteria for coverage of Lumizyme for patients with Pompe disease (acid alpha-glucosidase deficiency) for health benefit plans administered by Cigna Companies.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Metabolic Disorders - Cysteamine (Oral) Products for Individual and Family PlansDefines prior authorization, coverage criteria, and documentation requirements for Cystagon and Procysbi for members on Cigna Individual and Family Plans for treatment of nephropathic cystinosis.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Multiple Sclerosis (Injectable - CD20-Directed Cytolytic Antibody) - Ocrevus IntravenousDefines prior authorization, coverage criteria, dosing, and exclusions for ocrelizumab (Ocrevus) intravenous infusion for treatment of primary progressive MS and relapsing forms of MS for Cigna-administered plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Pombiliti (cipaglucosidase alfa-atga) for Pompe diseaseCigna coverage policy governing prior authorization, medical necessity criteria, dosing, and coding for Pombiliti (cipaglucosidase alfa-atga) used with miglustat (Opfolda) to treat late-onset Pompe disease in adults >40 kg.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Pulmonary Arterial Hypertension Endothelin Receptor AntagonistsDefines Cigna prior authorization, coverage criteria, and medical necessity for ambrisentan, macitentan, macitentan/tadalafil (Opsynvi), and bosentan for pulmonary arterial hypertension and selected other indications.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Somatostatin Analogs - MycapssaCigna's coverage policy for Mycapssa (octreotide delayed-release capsules) specifying prior authorization, prescribing clinician requirements, and medical necessity criteria for treatment of acromegaly in members of Cigna-administered health plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Stem Cell Transplantation: Blood CancersDefines Cigna's coverage stance and medical necessity criteria for hematopoietic stem cell transplantation (autologous, allogeneic, tandem) for blood cancers (e.g., ALL, AML, amyloidosis) and who it affects (members of Cigna-administered health benefit plans).All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Thymus Tissue TransplantationDefines medical necessity and coverage criteria for thymus tissue transplantation (cultured thymus tissue/Rethymic) in pediatric patients and documents coding, background, and supporting evidence for Cigna-administered plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Topical Acne-Non-Retinoid ProductsDefines medical necessity and coverage criteria for topical non‑retinoid acne products (e.g., clindamycin, minocycline, combination benzoyl peroxide products) for Cigna‑administered health plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Topical Acyclovir ProductsThis policy governs prior authorization and coverage criteria for topical acyclovir products (Zovirax 5% cream and ointment and generics) for Cigna-administered health benefit plans. It affects prescribers and pharmacists seeking coverage for topical acyclovir for members under Cigna plans.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-15Vafseo (vadadustat) for anemia in CKD on dialysisThis coverage policy governs prior authorization and medical necessity criteria for Vafseo (vadadustat tablets) for treatment of anemia due to chronic kidney disease in adults receiving dialysis, and describes excluded uses. It applies to Cigna-administered health benefit plans as detailed in the policy.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-13Zolgensma (onasemnogene abeparvovec) — Spinal Muscular Atrophy gene therapyCigna coverage policy governing prior authorization, medical necessity criteria, dosing, and documentation for one-time intravenous Zolgensma in patients with spinal muscular atrophy under 2 years of age.All Cigna updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-08Abortion — Treatment of Complications and Coverage CriteriaThis administrative policy describes Cigna coverage for abortion services and medically necessary treatment of complications following an abortion under standard Cigna benefit plans and explains relevant definitions and coding. It applies to providers submitting claims to Cigna and is governed by the terms of the applicable benefit plan and state regulations.All Cigna updates
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Tool Description
Search Cigna coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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