PHARMACY PRESCRIPTION BENEFIT
Part D Drug Formulary
Formulary listings, Utilization Management criteria, and any negative formulary changes for Cigna-HealthSpring formularies can be found at: http://www.cigna.com/medicare/resources/drug-list-formulary. Cigna-HealthSpring utilizes the United States Pharmacopeia (USP) classification system to develop Part D drug formularies that include drug categories and classes covering all disease states. Each category must include at least two drugs, unless only one drug is available for a particular category or class. Cigna-HealthSpring includes all or substantially all drugs in protected classes, as defined by CMS. All formularies are reviewed for clinical appropriateness by the national Cigna Pharmacy and Therapeutics (P&T) Committee, including the Utilization Management edits placed on formulary products. Cigna-HealthSpring submits all formulary changes to CMS according to the timelines designated by CMS.
A Part D drug is a drug that meets the following criteria:
- May be dispensed only by prescription
- Is approved by the FDA
- Is used and sold in the US
- Is used for a medically accepted indication
- Includes FDA-approved uses
- Includes uses approved for inclusion in the American Hospital Formulary Service Drug Information (AHFS DI), Micromedex, National Comprehensive Cancer Network (NCCN), Clinical Pharmacology, plus other authoritative compendia that the Secretary of Health and Human Services identifies, as off-label uses described in peer-reviewed literature are insufficient on their own to establish a medically accepted indication<
- Includes prescription drugs, biologic products, vaccines that are reasonable and necessary for the prevention of illness, insulin, and medical supplies associated with insulin that are not covered under Parts A or B (syringes, needles, alcohol, swabs, gauze, and insulin delivery systems)
Drugs excluded under Part D include the following:
- Drugs for which payment as so prescribed or administered to an individual is available for that individual under Part A or Part B
- Drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicaid (with the exception of smoking cessation products);
- Drugs for anorexia, weight loss or weight gain
- Drugs to promote fertility
- Drugs for cosmetic purposes and hair growth
- Drugs for symptomatic relief of coughs and colds
- Vitamins and minerals (except for prenatal vitamins and fluoride preparations)
- Non-prescription drugs
- Outpatient prescriptions for which manufacturers require the purchase of associated tests or monitoring services as a condition for getting the prescription (manufacturer tying arrangements)
- Agents used for treatment of sexual or erectile dysfunction (ED) (except when prescribed for medically-accepted indications such as pulmonary hypertension)
Part D Utilization Management
Cigna-HealthSpring formularies include utilization management requirements that include Prior Authorization, step therapy and quantity limits.
Prior Authorization (PA)
For a select group of drugs, Cigna-HealthSpring requires the customer or their physician to get approval for certain prescription drugs before the customer is able to have the prescription covered at their pharmacy.
Step Therapy (ST)
For a select group of drugs, Cigna-HealthSpring requires the customer to first try certain drugs to treat their medical condition before covering another drug for that condition.
Quantity Limits (QL)
For a select group of drugs, Cigna-HealthSpring limits the amount of the drug that will be covered without prior approval. The Centers for Medicare and Medicaid Services (CMS), in collaboration with the Pharmacy Quality Alliance (PQA), has identified certain medications as high risk when used in the elderly. This list is based upon the American Geriatrics Society (AGS) 2012 Updated Beers Criteria. All medications on the list are ones for which the AGS Expert Panel strongly recommends avoiding use of the medication in older adults. Use of these medications in the elderly may result in increased rates of adverse drug events, potential drug toxicity, and an increased risk of falls and/or fractures. Due to these safety concerns, Cigna-HealthSpring requires Prior Authorization for these medications in all customers aged 65 and older to confirm that the benefits outweigh the risks, and that safer alternatives cannot be used.
How to File a Coverage Determination
A Coverage Determination (CD) is any decision that is made by or on behalf of a Part D plan sponsor regarding payment or benefits to which an enrollee believes he or she is entitled. Coverage Determinations may be received orally or in writing from the customer’s prescribing physicians.
For the provider call center, please call: https://www.cigna.com/medicare/resources/2017-customer-forms 7 a.m. CST to 8 p.m. CST Monday through Friday or fax: 1-866-845-7267
The address is:
Coverage Determination and Exceptions
PO Box 20002
Nashville, TN 37202.
Any call received after 8 p.m. CST will be routed to a voicemail box and processed daily. To ensure timely review of a CD and that the prescriber is aware of what Cigna-HealthSpring requires for the most commonly requested drugs, forms are available online at https://www.cigna.com/medicare/resources/2018-customer-forms or by requesting a fax when calling 1-877-813-5595. A provider will receive the outcome of a Coverage Determination by fax no later than seventy-two (72) hours after receipt for standard requests or receipt of the supporting statement and no later than twenty-four (24) hours after receipt for urgent requests or receipt of the supporting statement.
The following information will be provided: 1) the specific reason for the denial taking into account the customer’s medical condition, disabilities and special language requirements, if any; 2) information regarding the right to appoint a representative to file an Appeal on the customer’s behalf; and 3) a description of both the standard and expedited redetermination processes and timeframes including conditions for obtaining an expedited redetermination and the appeals process. The fax cover sheet includes the peer-to-peer process if a provider has questions and wants to review with a clinical pharmacist.
How to File a Part D Appeal
A Part D Appeal can be filed within 60 calendar days after the date of the Coverage Determination decision, if unfavorable. Cigna-HealthSpring will ask for a statement and select medical records from the prescriber if a customer requests a Part D appeal. For an expedited appeal, Cigna-HealthSpring will provide a decision no later than seventy-two (72) hours after receiving the appeal, and for a standard appeal, the timeframe is seven (7) days. A provider can indicate if the request is expedited and that the condition of the patient could be seriously jeopardized if the decision is made in the standard timeframe. If the request is regarding payment for a prescription drug the customer already received, an expedited appeal is not permitted.
Part D appeals may be received orally or in writing from the customer’s prescribing physicians by calling:
1-866-845-6962 or fax 1-866-593-4482.
The mailing address is:
Part D Appeals
PO Box 24207Nashville, TN 37202−9910