MOUD Naltrexone LA denied as non-formulary by Cigna?

Cigna's specific coverage criteria for moud naltrexone la 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 Denies Long-Acting Naltrexone as Non-Formulary — and What to Do

A non-formulary denial means Cigna's current drug formulary either does not include long-acting injectable naltrexone at a covered tier or requires an exception before it will be covered. This is a procedural barrier, not a clinical one — and it is regularly overturned on appeal when the medical record supports the prescribing decision.

## Why This Denial Is Appealable

Federal parity law prohibits applying more restrictive non-formulary barriers to substance use disorder medications than to comparable medical conditions. If Cigna covers other injectable medications for chronic conditions without a formulary-exception hurdle, denying an FDA-approved MOUD through a more burdensome formulary process may constitute a parity violation. Your appeal should raise both the formulary-exception pathway and a parity argument.

## Your Federal Appeal Rights

• Formulary exception / internal appeal: Request a formulary exception in writing immediately. Under ACA and most state laws, you have the right to an exception when a formulary alternative is clinically inappropriate or unavailable. Cite ASAM or other applicable addiction medicine guidelines.
• External review (ACA §2719): If the formulary exception and internal appeal are denied, request IRO review. The standard window is approximately four months from the initial denial. Expedited review is available if delay risks serious harm.

## Appeal Timeline

1. File a formulary-exception request on the same day as the denial, attaching the prescriber letter. 2. Simultaneously file the formal internal appeal. 3. If both are denied, request external IRO review within the statutory window.

## Documentation to Gather

• Diagnosis and severity: Chart documentation of OUD or AUD diagnosis and clinical severity.
• Formulary alternatives considered: A statement from the prescriber explaining why covered formulary alternatives (if any exist) are clinically inappropriate, contraindicated, or have been tried and failed — referencing chart facts without needing to assert specific doses here.
• Prescriber letter: Explains the clinical rationale for long-acting naltrexone specifically (adherence considerations, clinical factors documented in the chart).
• Parity argument: A written statement identifying a comparable non-behavioral chronic condition for which Cigna covers injectable medications without equivalent non-formulary barriers.

## Criteria-Mapping Structure

Request Cigna's formulary-exception criteria in writing. For each requirement listed, map the exact chart fact that satisfies it. Submit this as a numbered exhibit alongside the prescriber letter. If Cigna's response is a new denial based on revised reasoning, that triggers a fresh appeal right.