Forteo denied as non-formulary by Cigna?

Cigna's specific coverage criteria for forteo are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Denied Forteo as Non-Formulary

A non-formulary denial means teriparatide (Forteo) is not included on Cigna's preferred drug list for your specific plan tier, so the plan will not pay for it at the standard covered rate — or at all. This is a coverage and cost-structure decision, not a clinical finding, but it is still fully appealable.

Non-formulary appeals succeed most often when you can show that every formulary alternative is medically inappropriate for your specific case, or that a formulary alternative was already tried and failed.

## Federal Appeal Framework

• Internal appeal (formulary exception): Most plans are required to offer a formulary exception process. Submit a prescriber-supported exception request demonstrating that the non-formulary drug is medically necessary and that formulary alternatives are clinically unsuitable. Cigna must respond within 30 days (non-urgent) or 72 hours (expedited).
• External review (ACA §2719 / ERISA §503): If the formulary exception is denied internally, you may escalate to an independent external review within approximately 4 months of the denial. The IRO evaluates whether the non-formulary drug is medically necessary given the unavailability or unsuitability of formulary options.

## Documentation to Gather

1. Formulary alternative history: A dated list of every formulary osteoporosis agent you have taken — with outcomes, duration, and documented reason each was stopped. If formulary alternatives are antiresorptive agents, your prescriber should explain why an anabolic agent is needed instead. 2. Contraindication or intolerance documentation: If any formulary alternative is contraindicated or not tolerated for you specifically, physician documentation of that fact (with chart support) is critical. Do not assert a contraindication unless the treating physician documents it. 3. Diagnosis and severity documentation: DXA results, fracture history, and physician notes confirming severity level. 4. Prescriber medical-necessity / exception letter: A letter explicitly requesting a formulary exception, identifying each formulary alternative, and explaining why each is clinically inadequate for your case.

## Criteria-Mapping Structure

Obtain Cigna's formulary exception criteria from the Evidence of Coverage document or by calling member services. List each criterion. For each one, provide the chart fact or prescriber statement that satisfies it. A structured, point-by-point letter is far more persuasive than a general narrative, particularly for formulary exception reviewers who are evaluating dozens of requests.