CommercialPrior AuthMedium impact
Cigna Specialty Care Options programs drug list changes
Cigna·Oncology, Hematology, Internal Medicine +1 more·Prior Authorization
Effective date
Sep 1, 2026
We identified it
Sep 9, 2026
Summary
Cigna is expanding its Specialty Care Options (SCO and SCO+) programs to include additional specialty medications effective September 1, 2026, and January 1, 2027. These drugs will now require site-of-care review to determine if administration can occur in a less-intensive setting (office, home infusion, or ambulatory center) rather than hospital outpatient settings. Billing teams must identify claims for these medications and ensure prior authorization includes site-of-care medical necessity documentation.
Action Required
By September 1, 2026: Billing team must implement prior authorization requirement for Revtorypyk (gedatolisib) and Sarclissa Escena (isatuximab-irfc) claims under Cigna SCO/SCO+ plans. By January 1, 2027: Expand prior authorization requirements to include Aranesp (non-ESRD use), Avtozma, Libtayo, Nplate, Retacrit (non-ESRD use), and Tyenne IV. For all affected drugs: (1) Update billing system to flag claims for site-of-care medical necessity review before submission; (2) Coordinate with providers to document clinical rationale for proposed administration site; (3) Route claims through prior authorization workflow to confirm less-intensive site of care is not clinically appropriate; (4) Educate clinical staff that Cigna may redirect patients to contracted office-based, home infusion, or ambulatory infusion centers. Failure to obtain prior authorization will result in claim denials or payment reductions.