Specialty Medical Injectables with Reimbursement Restriction

April 1, 2024

Our Specialty Medical Injectables with Reimbursement Restriction guidelines state that certain injectables must be dispensed and their claims must be submitted by a Cigna Healthcare–contracted specialty pharmacy, unless otherwise authorized by Cigna Healthcare.

The reimbursement restriction:

  • Applies when the specialty medical injectable is administered in an outpatient hospital setting.
  • Applies to specialty medical injectables covered under the customer’s medical benefit. Coverage is determined by the customer’s benefit plan.
  • Does not apply when the specialty medical injectable is administered in a provider’s office, non-hospital-affiliated ambulatory infusion suite, or home setting.

Specialty Medical Injectables with Reimbursement Restriction list expansion

We recently expanded the Specialty Medical Injectables with Reimbursement Restriction list to include the specialty medical injectables listed below.*

NameDate added
ELREXFIO™ (elranatamab-bcmm)October 1, 2023
Veopoz (pozelimab-bbfg)October 1, 2023
POMBILITITM (cipaglucosidase alfa-atga)November 8, 2023

Additional information

To access the Specialty Medical Injectables with Reimbursement Restriction list, log in to the Cigna for Health Care Professionals website (CignaforHCP.com) > Resources > Reimbursement and Payment Policies > Precertification Policies > List of Specialty Medical Injectables with Reimbursement Restriction. We recommend you review this list frequently, as it is subject to change. Specialty medical injectables may be added upon U.S. Food and Drug Administration approval.

* Cigna Healthcare may grant an exception to reimburse a one-time, or single, administration billed by a facility when a customer needs access to the injectable before it can be obtained from a specialty pharmacy with which Cigna Healthcare has a reimbursement arrangement.

How are we doing?

Please let us know what you think of the Provider Newsroom information and news.

Contact Us