EFFECTIVE DATE: 1/1/2021
Page 1 of 4
Coverage Policy Number: IP0010
Drug and Biologic Coverage Policy
Effective Date ............................................ 1/1/2021
Next Review Date… ..................................... 1/1/2022
Coverage Policy Number ............................... IP0010
Famotidine
Table of Contents
Overview .............................................................. 1
Coverage Policy Statement ................................. 1
FDA Indication Criteria ......................................... 2
Other Uses with Supportive Evidence Criteria .... 2
Specific Additional Criteria ................................... 2
Preferred Product Requirement Criteria .............. 2
Conditions Not Covered....................................... 2
Background .......................................................... 3
References .......................................................... 3
Related Coverage Resources
INSTRUCTIONS FOR USE
The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of
business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan
language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting
certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document
[Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may
differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan
document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit
plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage
mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific
instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular
situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for
treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support
medical necessity and other coverage determinations.
Overview
This policy supports medical necessity review for famotidine (Pepcid).
Coverage Policy Statement
Famotidine (Pepcid) is medically necessary when the following are met:
1. Criteria associated with FDA Indications
2. Criteria associated with Other Uses with Supportive Evidence
3. Specific Additional Criteria [when part of Cigna managed drug list or plan requirements]
4. Preferred Product Requirement Criteria [when part of Cigna managed drug list or plan requirements]
When coverage is available and medically necessary, the dosage, frequency, duration of therapy, and site of
care should be reasonable, clinically appropriate, and supported by evidence-based literature and adjusted
based upon severity, alternative available treatments, and previous response to therapy.
