Policy Updates June 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective June 15, 2017:
Bariatric Surgery - (0051) Modified
  • Important changes in coverage criteria:
    • Added coverage for biliopancreatic diversion without duodenal switch (BPD without DS).
    • Removed the > 50 body mass index (BMI) requirement for biliopancreatic diversion with duodenal switch (BPD/DS).
    • Added new coverage criterion for comorbidity of fatty liver disease.
    • Added to existing list of not covered procedures:
      • band over bypass
      • band over sleeve
      • stomach aspiration therapy - AspireAssist
      • endoscopic closure devices
        • Note: all require precert and are currently denied—no change in coverage.
Obstructive Sleep Apnea Treatment Services - (0158) Modified
  • Important changes in coverage criteria:
    • Moved diagnostic-related content to Sleep Testing Services – (0524).
    • Policy now addresses only treatment services.
      • Note: No change in coverage.
    • Updated title to reflect change.
Sleep Testing Services – (0524) New
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective June 15, 2017:
Afrezza® - (1506) Modified
  • Important changes in coverage criteria:
    • Added injectable for clarification for short-acting insulin.
    • Removed visual impairment as an example for unable to administer.
Controlled Substance Analgesics and Narcotic Antagonist Quantity Limitations - (1706) Modified
  • Important changes in coverage criteria:
    • Increased quantity limit for Xtampza ER 27mg to 4 capsules per day and 36mg to 8 capsules per day.
    • Clarified quantity limit is per 30 days for Hydrocodone-Acetaminophen.
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria:
    • Added:
      • brigatinib (Alunbrig)
      • durvalumab (Imfinzi)
      • letrozole and ribociclib co-packaged (Kisqali Femara Co-Pack)
      • midostaurin (Rydapt®)
      • niraparib (Zejula)
Oral Phosphodi-esterase-5 (PDE5) Inhibitors - (7003) Modified
  • Important changes in coverage criteria:
    • Changed “sexual” to “erectile” for consistency.
    • Added the following to list of uses considered experimental, investigational, or unproven (EIU):
      • continence recovery “re-enervation” status post radical prostatectomy
      • esophageal achalasia
      • lower urinary tract symptoms
Oxazolidinone Antibiotics - (1123) Modified
  • Important changes in coverage criteria:
    • Added coverage of linezolid (Zyvox) for treatment of a confirmed multidrug resistant tuberculosis (MDR-TB) infection as part of a multidrug regimen.
    • Changed title from product specific to drug class.
Pulmonary Hypertension Therapy - (6121) Modified
  • Important change in coverage criteria:
    • Added criteria that diagnosis of pulmonary hypertension is documented by right heart catheterization or echocardiogram.
Step Therapy – (1109) Modified
  • Important change in coverage criteria:
    • Added generic ezetimibe/simvastatin (Vytorin) to Step 1 for Statins under Global Step Therapy.
    • Added generic desvenlafaxine succ ER (Pristiq) to Step 1 and moved Pristiq (brand) from Step 2 to Step 3 for Selective Serotonin/Serotonin Norepinephrine Reuptake Inhibitors under Global Step Therapy.
Viscosupplementation for Osteoarthritis – (1405) Modified
  • Important change in coverage criteria:
    • Added Gelsyn, GenVisc, and Hymovis as nonpreferred products.
    • Simplified criteria from requiring both analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) to conservative treatment including physical therapy and/or pharmacotherapy.
      • Added minimum trial duration of at least six weeks.
Advanced notification of changes effective July 1, 2017:
Abatacept - (6112) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred.
      • Added details for early customer access for Actemra.
    • Decreased required number of anti-tumor necrosis factors (anti-TNFs) therapy for rheumatoid arthritis for employer groups.
    • Added Actemra step requirement for rheumatoid arthritis for employer groups.
    • Removed subcutaneous requirement from Orencia intravenous.
    • Expanded coverage of subcutaneous abatacept for polyarticular juvenile idiopathic arthritis to individuals two years and older.
Anakinra – (4063) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only
      • Added Remicade as preferred.
      • Added details for early customer access for Actemra.
    • Decreased required number of anti-TNFs therapy for rheumatoid arthritis for employer groups.
    • Added Actemra step requirement for rheumatoid arthritis for employer groups.
Anti Tumor Necrosis Factor Therapy - (9014) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred.
      • Added details for early customer access for Actemra and Cosentyx.
    • Added Inflectra criteria.
    • Modified Simponi Aria criteria:
      • Removed requirement of subcutaneous before intravenous.
    • Added criteria for off-label use:
      • Graft versus host disease and sarcoidosis.
    • Added body surface area (BSA) requirement to criteria for chronic plaque psoriasis.
    • Increased number of anti-TNFs for Cimzia and Simponi for employer groups.
Apremilast - (1414) Modified
  • Important changes in coverage criteria:
    • Removed anti-TNF requirement for plaque psoriasis for Otezla for employer groups.
    • Decreased anti-TNF requirement for psoriatic arthritis for employer groups.
    • Added BSA requirement to criteria for chronic plaque psoriasis.

Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601)

Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List - (1602)

Modified
  • Important changes in coverage criteria:
    • Multiple drugs and biologics added consistent with the general criteria approach outlined below:
      • Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same):
        • A maximum of five therapeutic alternatives required.
      • Multisource brand drugs:
        • Alternatives include generic equivalents, as well as therapeutic alternatives.
      • Single source combination products:
        • Alternatives include the individual components taken separately.
      • Non-preferred products (where applicable):
        • Alternatives limited to the preferred product(s)
Interleukin-12/23 and 17 Antagonists - (1017) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred
      • Added details for early customer access for Cosentyx.
    • Combined individual coverage policies for ixekizumab (Taltz), secukinumab (Cosentyx), and ustekinumab (Stelara) into one policy.
    • Added BSA requirement to criteria for chronic plaque psoriasis.
    • For Cosentyx and ankylosing spondylitis or psoriatic arthritis:
      • Changed number of anti-TNFs required from “two” to “one” for employer groups.
    •  For Stelara:
      • Added coverage for recent FDA approved indication Crohn’s disease with requirement of either Humira or Remicade.
      • For psoriatic arthritis:
        • Changed number of anti-TNFs required from “two” to “one” for employer groups.
      • For plaque psoriasis and psoriatic arthritis:
        • Added Cosentyx step for employer groups.
      • For Taltz and plaque psoriasis:
        • Added Cosentyx step for employer groups.
Natalizumab for Crohn’s Disease - (6017) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred.
    • Removed criteria requiring prior conventional therapies.
Tocilizumab - (1024) Modified
  • Important changes in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred
      • Added details for early customer access for Actemra.
    • Decreased required number of anti- TNFs therapy for rheumatoid arthritis for employer groups.
    • Removed subcutaneous requirement from Actemra intravenous.
    • Removed Castleman’s Disease as an EIU use:
Tofacitinib – (1410) Modified
  • Important change in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred
      • Added details for early customer access for Actemra.
    • Decreased required number of anti-TNF therapy for rheumatoid arthritis for employer groups.
    • Added Actemra step for rheumatoid arthritis for employer groups.
    • Added noncoverage statement for hair growth or skin pigmentation:
      • Considered cosmetic; therefore, excluded under standard benefit plans.
Vedolizumab – (1502) Modified
  • Important change in coverage criteria:
    • Revised criteria for business decision changes for employer groups only:
      • Added Remicade as preferred.
    • Removed criteria requiring corticosteroid or immunomodulator from Chron’s disease.
    • Revised criteria requiring corticosteroid or immunomodulator to one conventional therapy for ulcerative colitis.
Opioid Therapy – (1704) New
  • Customers prescribed long-acting opioids may be subject to a prior authorization requirement.
    • Affects customers with no previous long-acting opioid use under a Cigna-administered health plan in the last 120 days.
Penicillamine and Trientine Hydrochloride – (1703) New
  • Supports pharmacy prior authorization.
Ixekizumab (Taltz) – (1609) Retired
Secukinumab (Cosentyx®) – (1512) Retired
Policies Status Details
Administrative Policies
No updates for June 2017.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Sixteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
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Policies Status Details
Precertification Policies*
Updates have been made to the following:
Master Precertification List Modified
Policies Status Details
Reimbursement Policies*
Updates have been made to the following:
Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers – (HCPCS) Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for June 2017
Policies Status Details
Policies with a Reduction in Coverage
There were no additional changes made in June 2017 that resulted in a reduction in coverage.

These policies apply to health benefit plans administered by Cigna companies and are intended to provide guidance in interpreting certain standard Cigna benefit plans. Please note, the terms of a customer's particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these policies are based. For example, a customer's benefit plan document may contain a specific exclusion related to a topic addressed in a policy. In the event of a conflict, a customer's benefit plan document always supersedes the information in the policies.
In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including these policies and; 4) the specific facts of the particular situation. These policies relate exclusively to the administration of health benefit plans and are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.