The CIGNA HealthCare Pharmacy and Therapeutics Committee, a panel of participating network doctors and pharmacists,
regularly evaluates the safety and effectiveness of prescription medications that are included on the CIGNA Prescription Drug
List using the latest medical research and guidelines from the U.S. Food and Drug Administration (FDA) and national medical
organizations. This evaluation also includes the determination of which drugs will require prior authorization based on safety,
appropriate use or beneﬁt design. For medications or doses that require prior authorization, your doctor may call in the information or fax the appropriate prior
authorization form to CIGNA HealthCare to request coverage for the prescription. Your doctor should make this request before
writing the prescription. To determine if prior authorization is required, your doctor should check the CIGNA Prescription Drug
List or visit www.cigna.com for our complete prescription drug list. If the request is approved, the doctor will receive a fax conﬁrmation. The authorization will then be processed in our claim
system to allow you to have coverage for this drug. The length of the authorization will depend on the diagnosis and drug.
When your physician advises you that the drug has been approved, you should contact a participating pharmacy to ﬁll the
prescription(s). If the request is denied, you and your doctor will be notiﬁed that coverage for the drug is not authorized. If you have questions, please call Member Services at the toll-free number on your CIGNA HealthCare ID card. The following list identiﬁes the drugs that may require prior authorization and is subject to change on a quarterly basis. AGE indicates that the drug requires prior authorization if your age meets the age limit shown.
indicates that the drug routinely requires prior authorization to ensure appropriate treatment regimens are followed.
indicates that the drug requires prior authorization only when the quantity requested exceeds certain limits. Common Brand Name Common Brand Name Common Brand Name
“CIGNA” and “CIGNA HealthCare” are registered service marks and refer to various operating subsidiaries of CIGNA Corporation. Products
and services are provided by these operating subsidiaries and not by CIGNA Corporation. These operating subsidiaries include Connecticut
General Life Insurance Company, Tel-Drug, Inc. and its afﬁliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company
subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO Plans are offered by CIGNA HealthCare of
Arizona, Inc. In California, HMO plans are offered by CIGNA HealthCare of California, Inc. In Virginia, HMO plans are offered by CIGNA
HealthCare of Virginia, Inc. and CIGNA HealthCare Mid-Atlantic, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of
North Carolina, Inc. All other medical plans in these states are insured or administered by Connecticut General Life Insurance Company.
594266d Enhanced – All Modules, A, B & C (Beneﬁts Exclusion, Utilization & Unit Cost Management & Intensive Appropriateness of Use)
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