Frequently Asked Questions (FAQs) (cont.)
Q. What types of medications typically need approval? A. Medications that: • May be unsafe when combined with other medications • Have lower-cost, equally effective alternatives available • Should only be used for certain health conditions • Are often misused or abused Q. What types of medications typically have quantity limits? A. Medications that are often: • Taken in amounts larger than, or for longer than, may be appropriate • Misused or abused Q. What types of medications require Step Therapy? A. High-cost medications that are used to treat many conditions, such as : • ADD/ADHD • High cholesterol • Allergies • Osteoporosis • Bladder problems • Pain • Breathing problems • Skin conditions • Depression • Sleep disorders • High blood pressure Q. Why does my medication have an age requirement? A. The FDA considers certain medication to only be clinically appropriate for people of a certain age or within a certain age range . Q. How do I get approval (prior authorization) for my medication? A. Ask your doctor’s office to contact Cigna Healthcare to start the coverage review process. They know how the review process works and will take care of everything for you. In case the office asks, they can download a request form from Cigna Healthcare’s provider portal at cignaforhcp.com .
Cigna Healthcare will review information your doctor sends us to make sure your medication meets coverage requirements. We’ll send you and your doctor a letter with the decision and next steps. It can take 1-5 business days to hear from us. You can always check with your doctor’s office to find out if a decision’s been made. You can also log in to the myCigna App or myCigna.com to check the status of your approval. Click on Prescriptions, then choose My Medications from the dropdown menu. On the left side of the page under “Prior Authorization,” click the “View List” button. If your medication isn’t approved, your doctor can send us more information to review, using the same process as before. We’re happy to review the request again. Depending on what your doctor sends this time, we may be able to approve coverage. Or, you and your doctor can appeal the decision by sending Cigna Healthcare a written request explaining why the medication should be covered. Q. What happens if I try to fill a prescription that needs approval but I don’t get approval ahead of time? A. When your pharmacist tries to fill your prescription, he or she will see that the medication needs pre- approval from Cigna Healthcare. Because you didn’t get approval ahead of time, your plan coverage won’t apply. Meaning, your plan won’t cover the cost of your medication. You should ask your doctor to contact Cigna Healthcare to start the coverage review process. Or, you can choose to pay the medication’s full cost out-of-pocket directly to the pharmacy (the cost can’t be applied to your annual deductible or out-of-pocket maximum) . Q. What happens if I try to fill a prescription that has a quantity limit? A. Your pharmacist will only fill the amount your plan covers. If you want to fill more than what’s allowed, your doctor’s office will need to contact Cigna Healthcare to request approval for the larger amount.
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