Health insurance coverage policies are an integral part of our health care system that help protect the health and well-being – including the financial well-being – of all Americans. They enable access to safe and effective care in all forms of employer- and government-sponsored health benefit plans, and guide people to pharmacy, behavioral, and medical care grounded in current scientific evidence.

“Our data-driven, clinical-first approach to coverage policies is designed to guide patients and providers toward clinically appropriate, evidence-based and, where appropriate, cost-effective treatment, therapy, and services that aim to best help them.”Andy Behm, chief clinical guidance officer of The Cigna Group

We sat down with Andy Behm, who leads the team dedicated to ensuring coverage policies across The Cigna Group protect and enhance the health and well-being of the people we serve. Dr. Behm shared what is involved in the development, implementation, and maintenance of health plan coverage policies and how customers can learn more about the policies guiding their care.

How is a coverage policy for a specific treatment developed?

The core tenet my team and I follow regarding our coverage policy approach is “clinical-first.” This means we separate the clinical and financial factors, review the safety and appropriateness of a new medical procedure, lab test, or medication first, and then look to maximize affordability within the clinical framework.

To determine treatment safety and appropriateness, we collaborate with clinical experts both inside and outside of our organization to review the latest relevant medical literature and clinical data.

Do coverage policies change over time? And if so, how often?

Clinical evidence and medical knowledge and guidelines are constantly evolving, so our coverage policies evolve as well. It’s our job to ensure we have contemporary, up-to-date coverage policies that reflect the best medical practices available today. We have some policies that get updated three, four, five times a year or more. At a minimum, all policies are reviewed at least once every 12 months.

The pace of innovation in the pharmaceutical industry is a perfect example. In 2023, the FDA approved a record high of 72 unique biologics and new molecular entities, as well as hundreds of new drug indications and clinical line extensions and thousands of new strengths, dosage forms, and generics. All of this data needs to be reviewed with a sense of urgency so we can be sure our customers can obtain safe and appropriate care, when they need it.

"I see our coverage policies as fluid because we are always evolving with the latest data and evidence so we can better meet the needs of our clients and customers. And we’ve built a rigorous evaluation system that is appropriately staffed with experts who can thoughtfully analyze and evaluate every one of those updates."

In addition to keeping pace with the marketplace, we seek to predict future coverage policy needs. For example, we look at the drug patent pipeline and potential implications when drug formulary decisions are made. Planning for the future is very important as we help our clients manage health care access and delivery.

You’ve mentioned that our coverage policies are primarily driven by clinical data. What else does your team consider?

We take a data-driven, evidence-based approach. Our clinical policies are based on published peer reviewed literature, FDA labeling and clinical practice guidelines, so we can determine safety, effectiveness, and appropriateness of the medications, lab tests, and medical procedures for patients.

Further, all policies are reviewed and informed by practitioners – physicians and pharmacists – who apply a real-world lens. As an example, we commonly approve non-FDA-approved uses for a treatment or lab test if there is sufficient supporting evidence and practice experience. This includes the MammaPrint genetic test for potential recurrence of breast cancer. It is only FDA-approved for women with breast cancer who are lymph node-negative, but we will also cover the test for women who are lymph node-positive because the data and practice experience supports this use too.

Also, there are instances where the FDA and other regulatory bodies have provided extremely broad indications of use for a therapy or test that aren’t supported by the data. In each instance, we let the data guide our decision in terms of coverage. For example, the FDA has approved the use of Litfulo for severe alopecia areata, an autoimmune skin disease that causes hair loss. However, given what the data tells us about the health risks from long-term use of this type of drug, we cover its use only if a patient has a severe case of the disease, and has tried more conventional systemic therapies or a topical corticosteroid as a first-line treatment.

Tell us about the people involved in creating and maintaining our coverage policies.

I have almost 30 clinicians on my team – highly trained nurses, pharmacists, and physicians – creating coverage criteria for the standard programs we offer. The clinicians on the team also administer and apply the coverage criteria within the patient experience. They talk to treating practitioners every day to get their view on how well our coverage policies are working in their practice.

The team’s clinicians have extensive expertise in assessing and interpreting published medical literature. They are constantly reviewing and revising our coverage criteria so they are up to date, while also making sure the intent of the policy, which is to connect patients to appropriate and effective care, is carried through.

On top of that, The Cigna Group has over 20,000 clinicians on staff – including doctors, pharmacists, nurses, and social workers. A large percentage of them are involved in coverage reviews and they put coverage criteria into practice.

What is The Cigna Group doing to ensure people can understand and navigate their coverage policies?

We are committed to helping customers better understand their health benefits, including coverage policies. Customers can find more information on myCigna.com under the “Coverage” tab and clicking the “View the main features of your plan” link. It helps explain how the customer and their benefit plan share the costs of care as well as a glossary that explains coverage policy and medical terms in plain and simple language. In addition, we always welcome customers to contact our customer service team by phone or chat if they have any coverage questions.

We are working to streamline the application of our coverage policies, leveraging existing data to enable patients to have swift and appropriate access to the care they need. For example, when a physician prescribes a medication for a patient, we quickly apply the related coverage criteria so the patient can pick up the drug at a pharmacy within 24 hours. In cases where the drug prescribed is not in our formulary, or if there may be a more clinically appropriate and cost-effective therapy available for the patient, we immediately provide that information to the prescriber so they can make whatever adjustments they deem appropriate in the prescription before the patient sets foot in the pharmacy.

Do you look at coverage policies through the lens of health equity?

We absolutely consider health equity in coverage policies and seek to identify any barriers to safe, effective, and appropriate care and recommend policy changes to address those barriers as part of our review process. We leverage our health equity team led by Dr. Neema Stephens, our national medical director for health equity, to inform our coverage policies and improve equitable access to health care.

We also reach out proactively to our network providers to notify them of these updates, as well as potential health disparity situations that their patients may encounter, so they can be better prepared to help connect patients to the care they need.