Cigna

Cigna (now The Cigna Group, with Evernorth as its health services division) is a major commercial insurer with Express Scripts managing pharmacy benefits. Cigna uses coverage policy documents and National Drug Lists to determine coverage. Their process is structured but can be opaque.

Common Denial Patterns

• •Not on National Drug List — Cigna's formulary may not include the requested drug
• •Step therapy protocol not completed — Cigna requires specific prior therapy documentation
• •Express Scripts pharmacy benefit denial — drug requires pharmacy PA separate from medical PA
• •Utilization management criteria not met
• •Quantity limits or dose restrictions exceeded

Step Therapy Approach

Cigna's step therapy requirements are managed through Evernorth/Express Scripts for pharmacy benefit drugs and through Cigna medical policy for medical benefit drugs. Step therapy typically mirrors clinical guidelines but may include additional cost-based requirements like biosimilar-first policies.

Appeal Process

Appeals must be filed within 180 days of denial. Cigna provides appeal forms and accepts submissions via the provider portal, fax, or mail. Cigna is required to respond to standard appeals within 30 days and expedited appeals within 72 hours. External review is available through state insurance departments.

Tips for Appealing Cigna Denials

1. 1.Distinguish between Cigna medical benefit and Express Scripts pharmacy benefit — appeal processes differ
2. 2.Request Cigna's specific coverage policy for the drug in question before submitting the appeal
3. 3.For pharmacy benefit denials, work with Express Scripts directly
4. 4.Cigna peer-to-peer reviews are available and can be effective for specialty drug overturns
5. 5.Document all prior therapy trials with specific dates, doses, and duration — Cigna is strict on documentation