Policy Updates September 2017

Policies Status Details
Medical Coverage Policy
No updates for September 2017.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective September 15, 2017:
Ivacaftor, Lumacaftor/Ivacaftor - (1207) Modified
  • Important changes in coverage criteria:
    • Added coverage to align to FDA-approved expanded indication for additional cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations.
    • Removed trade name from title.
Oncology Medications - (1403) Modified
  • Important change in coverage criteria:
    • Added Idhifa (enasidenib).
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
    • Added criteria for:
      • Adrenaclick
      • Auvi-Q
      • EpiPen
      • EpiPen Jr.
      • Relistor tablet
Rituximab for Non-Oncology Indications - (5108) Modified
  • Important changes in coverage criteria:
    • Added statement that rituximab is experimental, investigational, or unproven (EIU) for:
      • lupus nephritis
      • membranous nephropathy
      • multiple sclerosis
      • myasthenia gravis
      • Sjogren’s Syndrome
      • systemic lupus erythematosus (SLE)
    • Added statement that Rituxan Hycela is EIU for non-oncology indications.
    • Removed trade name from title.
Step Therapy - (1109) Modified
  • Important change in coverage criteria:
    • Removed epinephrine auto-injector class.
Policies Status Details
Administrative Policies
Abortion - (A006) New
  • New policy, effective September 21, 2017:
    • Clarifies definitions and codes associated with abortion.
    • Retiring Abortion T107 Tool to Administer Benefit Standards (TABS).
Preventive Care Services – (A004) Modified
  • Important changes:
    • CPT codes 86480 and 86481
    • Adults at risk
  • Removed reference to HPV vaccine gender edit.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Fifteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
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Policies Status Details
Precertification Policies*
No updates for September 2017.
Policies Status Details
Reimbursement Policies*
No updates for September 2017.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for September 2017.
Policies Status Details
Policies with a Reduction in Coverage
There were no additional changes made in September 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.