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Cigna Specialty Care Options programs drug list changes
Act
by Sep 1, 2026
Effective date
Sep 1, 2026
Identified
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.
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What to do
by Sep 1, 2026 · 7 steps
01Billing team must implement prior authorization requirement for Revtorypyk (gedatolisib) and Sarclissa Escena (isatuximab-irfc) claims under Cigna SCO/SCO+ plans.
02By January 1, 2027: Expand prior authorization requirements to include Aranesp (non-ESRD use), Avtozma, Libtayo, Nplate, Retacrit (non-ESRD use), and Tyenne IV.
03For all affected drugs.
04Update billing system to flag claims for site-of-care medical necessity review before submission.
05Coordinate with providers to document clinical rationale for proposed administration site.
06Route claims through prior authorization workflow to confirm less-intensive site of care is not clinically appropriate.
07Educate clinical staff that Cigna may redirect patients to contracted office-based, home infusion, or ambulatory infusion centers.
If missed: Failure to obtain prior authorization will result in claim denials or payment reductions.
Original notice
Cigna Specialty Care Options programs drug list changes
providernewsroom.com · Always check the source before changing claims.