Specialty Drug (Humira) — Cigna
Score
Criteria
Submitted step therapy exception but did not include required lab results (ESR, CRP) documenting disease activity despite methotrexate.
Request submitted but flagged for additional clinical documentation by payer.
Patient
Patient
Robert Chen, 38M
Primary Dx
M06.09 — Rheumatoid arthritis
Payer
Cigna Open Access Plus
Drug
Adalimumab (Humira)
Failed Tx
Methotrexate (inadequate response)
BMI
22.5
Changes made by agent
Agent Activity
0:00
Read patient chart
Accessed rheumatology notes, medication history, lab results. Confirmed inadequate response to methotrexate.
0:15
Checked Cigna formulary
Adalimumab requires step therapy exception. Must document failed first-line DMARD therapy.
0:40
Gathered clinical evidence
Rheumatology consult notes documenting disease progression, current medication regimen, DAS28 score.
1:30
Filed step therapy exception
Submitted exception request documenting inadequate response to methotrexate over 6+ months.
2:45
Submitted prior auth request
Submitted prior auth via Cigna portal with step therapy exception and clinical justification.
4:12
Additional documentation requested
Cigna requested ESR and CRP lab results to verify ongoing disease activity. Auth pending.