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CIGNA Pharmacy Management: Clinical Programs

Supporting your patient care efforts

At CIGNA Pharmacy Management, we offer programs to customers focused on improving health and making medications more affordable. These programs support you and your patients who have both CIGNA pharmacy and medical benefits. If you have patients who could benefit from these programs, we may send you letters and/or reports with information specific to your patient and information on how these programs can help. Our pharmacy clinical programs include:

CoachRx: this program takes a proactive approach to help patients adhere to their medication therapy. Through pharmacy coaching and interactive tools, we help them understand whatís getting in the way, then work with them to overcome challenges, change behavior and improve their health. Eligible customers will receive a letter outlining the CoachRx program and will be directed to to enroll. In addition, all individuals using CIGNA Home Delivery program have access to the program

Once enrolled, they can sign up for reminders to take medications, order refills, check vital signs or schedule doctor appointments. They can get free pillboxes and coupons on select prescriptions and over the counter drugs. Individual coaching services and pharmacist referrals are available to address adherence issues like dosing schedules, side effects or cost. And, they can receive advice on issues such as side effects, ways to save money and more.

If your patient has CIGNA pharmacy coverage and could benefit from this free program, we encourage you to send them to CIGNA Home Delivery (1.800.285.4812) to enroll in the program.

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Complex Psychiatric Case Management: this program is designed to help patients taking multiple psychotropic drugs. Specifically, this program targets patients on a complex psychotropic medication regimen who, according to our records, arenít seeing a behavioral health clinician. The program looks at medications commonly used to manage a variety of psychiatric conditions including the following:

  • Antidepressants
  • Benzodiazepine
  • Stimulants
  • Anxiolytics
  • Sedative hypnotics
  • Anticonvulsants
  • Antipsychotics
When our records indicate that a patient is taking multiple psychotropic drugs, CIGNA will send you a report that provides an overview of the program and a detailed profile of the patientís six-month prescription history. The six-month report includes the drugs they are taking and whether or not they are complying. Patients do not receive communications from CIGNA as part of this program. These reports are designed to notify you of the information in our system that may help you manage your patientís treatment plan. Your patients can access information on their page. Health care professionals should go to for more information.

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Medication Safety Program: this program uses comprehensive medical and pharmacy information to form a complete view of patientsí medical conditions and prescription drug use. By analyzing medical diagnoses, prescription histories and the number of physician and pharmacy visits over a time period, we are able to generate detailed patient profiles and send them to you and the patientsí other physicians. The program checks if the patient has:

  • A documented history of substance abuse;
  • Multiple physicians prescribing narcotics and other controlled substances;
  • Multiple pharmacies filling prescriptions for narcotics and other controlled substances, or
  • High prescription fill quantities of any prescribed narcotic.
When our systems reveal one or more of the above situations, our program flags it, and sends a medication-use profile to all of the patientís prescribing physicians. With this information, you can see a complete picture of your patientsí situation and can determine if further investigation, evaluation or action is needed. Patients do not receive communications from CIGNA about his program. CIGNA also offers you the ability to restrict a patient to a single prescribing physician or a single pharmacy to receive a specific medication. This allows patients to continue with their medication therapies, but controls how and where they can obtain their medications, thereby managing overuse and potential abuse. We also offer a toll-free number for you to contact our Special Investigation Unit (SIU) if you feel that these medications may have been obtained fraudulently.

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Step Therapy: Some CIGNA Pharmacy benefit plans have introduced this clinical cost management program. This prior authorization program creates a sequence of "steps" in the choice of medications. The program is designed to encourage the use of cost-effective clinically appropriate agents before moving to more costly alternatives, unless prior authorization for coverage under the benefit plan is obtained. Criteria for authorization includes failure, intolerance or contradiction of the prerequisite agents.

The Two Step process is described below. The other Step Therapy variations work in a similar fashion:

  • Patient tries a Step 1 medication, typically a generic. Prior authorization is not need for Step 1 medications.
  • If a patient tries a Step 1 medication and it is not successful, then the Step 2 medications (typically Preferred Brands) would be eligible for coverage without need for prior authorization.
  • If a patient tries a Step 1 and a Step 2 medication and it is not successful, then the Step 3 medications (typically Non Preferred Brands) would be eligible for coverage without need for prior authorization.
At any time, you can request prior authorization for coverage for a Step 2 or Step 3 medication if clinically indicated. All pre-existing prior authorizations will continue to be honored. To help minimize disruption, the first fill of a medication subject to Step Therapy requirements will be covered without interruption, but will trigger written notification to you and your patient, advising that action needs to be taken before the next fill. Also, upon introduction of the Step Therapy program, many plans will incorporate an initial Grace Period, typically 60 days, during which time the program is not yet active at dispensing pharmacies, but introduction letters are sent to patients alerting them of the new program.

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TheraCare® Specialty Therapy Management: this targeted condition drug therapy management program is for individuals who use specialty injectable medications for certain chronic conditions. The program aims to help them better understand their condition, medication, side effects and the importance of adherence.

Individuals treated with conditions using injectable medications are eligible for the program at the point of initial prior authorization approval or injectable claim payment. Therapy Support Coordinators will reach out to eligible individuals to encourage program participation and engage with ongoing education and support. With the individualís consent, he/she will be enrolled in the program.

The enrolled individual will interact with a trusted support team that will help increase compliance, improve outcomes, manage medication side effects, identify potential drug interactions, direct treatment options to lower net cost alternatives and increase their overall quality of life. Written communications will also be sent to you along the way to keep you up to date on the status of the patient pertaining to his/her participation in the program.

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Well Informed (Gaps in Care): this program uses the most up-to-date evidence-based medical care standards to identify potential gaps for your patients. The program addresses disease prevention and focuses on over 30 chronic illnesses and acute conditions including diabetes, COPD, hypertension, depression, high cholesterol and more.

Each month, CIGNA Well Informed program analyzes an individualís laboratory claims and results, pharmacy and medical claim data against evidence-based medical standards to identify potential gaps. When a possible gap is identified, it triggers a set of communications to our clinical team, the patient and you:

  • Our clinical teams and wellness coaches are notified of the potential gap
  • You, as the patientís physician, will receive a letter with patient-specific information for your patients with new gaps. Physician letters may be sent to more than one physician if a specialist is involved in care.
  • The patient will receive a personalized letter with detailed information about the gap, the data that led us to identify the gap, why addressing the gap is important, what steps to take and how to get more information.

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