What Changed

Cigna has significantly expanded its GLP-1 therapy coverage for both adults and pediatric patients. The update broadens the use of Wegovy (semaglutide), Saxenda (liraglutide), and Zepbound (tirzepatide) beyond traditional obesity management, now encompassing cardiometabolic risk reduction and obstructive sleep apnea.

Policy Summary

• Broader Eligibility: Coverage for adults with BMI ≥ 27 kg/m² plus at least one comorbidity (e.g., hypertension, T2DM, dyslipidemia).
• Pediatric Inclusion: Saxenda approved for patients ≥ 60 kg meeting clinical obesity criteria.
• Cardiovascular Indication: New coverage for obesity with established cardiovascular disease.
• Obstructive Sleep Apnea (OSA): Added Zepbound for patients with moderate-to-severe OSA.
• Extended Coverage Duration: Up to 1 year for pediatric use.
• Titration Guidance: Pediatric Saxenda users may reduce to 2.4 mg daily if intolerant of 3 mg; escalation window extended to 8 weeks.
• Clinical Documentation: Must include BMI reassessment after 12 weeks and chart documentation of comorbid conditions.
• Concurrent Therapy: Clarified exclusion, cannot be combined with other FDA-approved weight-loss drugs.

Why It Matters for RCM Teams

• Expect increased GLP-1 therapy claims under expanded ICD-10s for obesity, CVD, and OSA.
• Denial prevention depends on accurate documentation of BMI, comorbidities, and progress at 12 weeks.
• Prior authorization remains, but criteria are now clearer, improving predictability in approvals.

Reimbursement Impact

• Potential higher claim volume for obesity and OSA-related care episodes.
• Enhanced payment compliance via newly defined medical necessity language.
• Anticipate payer audits for duplicate GLP-1 therapies in concurrent claim submissions.

What Changed

Cigna Healthcare has removed prior authorization requirements for Methadone used in Opioid Use Disorder (OUD) treatment within certified Opioid Treatment Programs (OTPs).

This policy streamlines access to methadone maintenance therapy and aligns with national goals to expand timely access to medication-assisted treatment (MAT) for opioid dependence.

Policy Summary

• Prior Authorization: No longer required for methadone prescribed under approved OTPs.
• Program Eligibility: Applies only to state-licensed, SAMHSA-certified treatment centers.
• Documentation: Standard claim documentation (NPI, program certification) remains mandatory.
• Other OUD Medications: Prior authorization for buprenorphine and naltrexone remains unchanged.
• Reimbursement Scope: Applies to initial treatment and ongoing maintenance therapy.

Why It Matters for RCM Teams

• Accelerates claims processing — reduces delays caused by PA review.
• Improves patient retention in OUD programs, minimizing treatment gaps.
• Decreases administrative burden for RCM teams managing addiction recovery billing.
• May influence denial rates if documentation of certified OTP participation is missing.

Reimbursement Impact

• Immediate eligibility for methadone maintenance billing under OTP codes.
• Faster payment cycles and reduced rework in addiction treatment claims.
• Encourages cross-functional coordination between behavioral health and medical billing teams.