Posted in Cinga Insurance

Cigna- Drug Formulary Changes effective January 2022

In this blog post we will explore the changes that affect Specialty medications for both medical and pharmacy benefits.


What does this mean for providers?

Please check to see which changes apply to your patients. Please contact Cigna or check on their website CignaforHCP.com for more specialty drug changes and any other suitable alternatives.


What does this mean for patients?

Patients that get their medication from a pharmacy may see higher out of pocket costs. Please contact your healthcare provider to see if there are any other suitable alternatives.  


Medical Benefit Specialty Medications:

  1. Immuno globulins: Cigna preferred drugs are Flebogamma, Gamunex-C, Gammaked, Gammaplex, Hizentra, Octagam, and Privigen. Any other Immuno globulins that are on the non-preferred list will require a step therapy. Cinga is letting the current authorizations for non-preferred immune globulins be active until the authorization expiration date. After which the provider will need to reevaluate the patient for any preferred drugs.
  2. Iron Replacement: Cigna will require a prior authorization for following iron replacement drugs-Feraheme, Injectafer, and Monoferric. These drug will also have step therapy that will go through Verofer. This requirement does NOT apply for patients with dialysis-dependent chronic kidney disease. IF the patient has a pharmacy benefit (Advantage and Performance Formularies) will require a prior authorization WITH a step therapy.
  3. Neutropenia: Udenyca will no longer will be on the preferred list. Patients that currently take Udenyca are allowed to keep taking it until their current authorization will expire. (Patients that do have a three-tier pharmacy benefit MAY see their cost share change, if they fill the Rx under their pharmacy benefit).  Cigna will make Ziextenzo a preferred medication and will be added to the list with Neulasta, Neulasta Onpro, and Nyvepria.
  4. Pulmonary Hypertension: Remodulin-will require a step therapy through treprostinil (generic equivalent)
  5. Transplant Therapy: Nulojix will require precertification and may require a site of care review.

Pharmacy Benefit Specialty Medications:

  1. HIV medications: Cigna will REMOVE the following medications from the formulary-Kaletra, Atripia, Emritva, Intelence, and Symfi/Symfi Lo.
  2. Multiple Sclerosis: For patients that start the treatment and providers that initiate a new prior authorization-all single-source brands (oral, injectable, and infusion medications, will have a step therapy requirement.
  3. Oncology: Cigna will put Tasigna on a non-preferred list. For any new treatment and initiated prior authorizations there will be a step therapy requirement.

For a full list of Medication/drug formulary changes for the year 2022, please click here.


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Posted in BCBS Empire NY, Pharmacy (Various Insurance Payers), Training, Updates

Empire BCBS (NY) Specialty Pharmacy Changes updates for 2021

Reminder #1:

  1. Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.
  2. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.

New Clinical Criteria effective December 22, 2020

The following clinical criteria is new.

  • ING-CC-0184 Danyelza (naxitamab-gqgk)

New Clinical Criteria effective June 1, 2021

The following clinical criteria is new.

  • ING-CC-0185 Oxlumo (lumasiran)

Revised Clinical Criteria Effective 12/22/2020:

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0124 Keytruda (pembrolizumab)

Revised Clinical Criteria effective January 25, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0015 Infertility and HCG Agents
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Revised Clinical Criteria effective January 25, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0079 Strensiq (Asfotase Alfa)
  • ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)

Revised Clinical Criteria effective June 1, 2021

The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.

  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0154 Givlaari (givosiran)

Reminder #2:

Effective June 12, 2021, Empire BCBS NY will be implementing coding updates in the claims system for the following clinical criteria listed below which may result in not medically necessary determinations for certain services.

  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6

To view the complete policies, please visit the following links:

  1. Danyelza
  2. Oxlumo
  3. Keytruda
  4. Colony Stimulating Factor Agents
  5. Infertility and HCG Agents
  6. Botulinum Toxin
  7. Givlaari
  8. Strensiq
  9. Zilretta

Posted in In The Know Series, Insurance, My services

EmblemHealth new Specialty Pharmacy for 2019

According to EmblemHealth, starting in 01/01/2019- the new Specialty Pharmacy will be Accredo. Accredo which is a subsidiary of an Express Scripts, is already a specialty pharmacy for other insurance companies like 1199, BCBS.

Starting on 01/01/2019 EmblemHealth providers will need to send RX’s for specialty medications, to the Accredo pharmacy.

Some of the specialty medications would be: Xolair, Dupixent, Fasenra, Nucala.