CurrentAetnaPolicy N/A

Vectibix (panitumumab) Injectable Medication Precertification Request

Aetna precertification request form to collect patient, prescriber, insurance, dispensing, product, diagnosis and clinical information to request authorization for Vectibix (panitumumab) initiation or continuation of therapy. It documents required clinical fields for review but does not itself state coverage criteria or reimbursement rules.

Policy Summary

PayerAetna

PolicyVectibix (panitumumab) Injectable Medication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form / informational

Effective Date

Next Review Date

Key ActionProvider must submit completed precertification request form with all required clinical, administrative, and diagnosis information for initiation or continuation of Vectibix (panitumumab) to Aetna Precertification Notification via phone or fax; incomplete or illegible forms may delay review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is an administrative precertification request form (no substantive policy/coverage updates).

2Form pages

VectibixDrug

Colorectal cancerIndication

Summary

This is Aetna's precertification request form titled "Vectibix (panitumumab) Injectable Medication Precertification Request." The form is used to collect patient, prescriber, insurance, dispensing, product, diagnosis, and clinical information to request authorization for Vectibix for colorectal cancer. The form is informational and used by Aetna to evaluate authorization requests; it does not itself constitute the coverage policy or reimbursement rules. The document indicates it is a multi-page form (Page 1 of 2) and primarily focuses on colorectal cancer as the indication.

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Clinical documentation requirements (Initiation & Continuation)

Information required for Initiation Requests

Information required for Initiation Requests: Complete all of the following.

ALL of the following

Indication: Colorectal cancer (including appendiceal carcinoma, anal adenocarcinoma, colon cancer, and rectal cancer).
Clinical setting (ONE of): Unresectable/inoperable disease; Advanced disease; Metastatic disease; Other.
Select one clinical setting.
Prior cetuximab (Erbitux) failure: Document whether the patient previously experienced clinical failure on cetuximab (Yes/No).
RAS mutation status: RAS (KRAS and NRAS) mutation status is negative (wild-type) or provide mutation details.
Place in therapy: First-line treatment or Subsequent treatment (select one).
Primary tumor location and sidedness: Is this request for treatment of colon cancer? (Yes/No). Is the tumor left-sided? (Yes/No).
BRAF V600E status: Is the tumor positive for BRAF V600E mutation? (Yes/No).
Concomitant encorafenib: Will the requested drug be used in combination with encorafenib (Braftovi)? (Yes/No).
KRAS G12C mutation positive / Requested regimen (ONE of requested regimens): Indicate if KRAS G12C mutation positive and select regimen: In combination with sotorasib (Lumakras); In combination with adagrasib (Krazati); Other.
Prior chemotherapy: Has the patient previously received treatment with chemotherapy? (Yes/No).
Other/unknown mutation: Provide other or unknown mutation details if applicable.

Information required for Continuation Requests

Information required for Continuation Requests: Complete all of the following.

ALL of the following

Date of last treatment: Provide the date of the most recent Vectibix administration (MM/DD/YYYY).
Evidence of disease progression or unacceptable toxicity while on the current regimen: Provide documentation indicating whether there is disease progression or unacceptable toxicity (Yes/No) and supporting clinical notes/imaging/labs.

Administrative / Form completion requirements

Administrative / Form completion requirements: All administrative fields must be completed and legible for precertification review.

ALL of the following

Patient demographics: First and last name, address, city, state, ZIP, DOB, contact phone numbers, weight, height, allergies, and e-mail.
Insurance information: Aetna Member ID #, Group #, insured name, other coverage (Yes/No) with other carrier and ID#, Medicare (Yes/No) with ID#, Medicaid (Yes/No) with ID#.
Prescriber information: Prescriber first and last name, credentials (M.D., D.O., N.P., P.A.), address, city, state, ZIP, phone, fax, state license number, NPI, DEA, UPIN, provider e-mail, office contact name and phone, and specialty.
Dispensing provider / administration information: Place of administration (self-administered, physician's office, outpatient infusion center, home infusion center), facility/center name and phone, administration CPT code(s), dispensing provider/pharmacy (physician's office, retail pharmacy, specialty pharmacy, other) with name, address, phone, fax, TIN, PIN, and selected patient choice.

What providers must do

Prior Authorization

Precertification submission required

Provider must submit the completed Vectibix precertification request form with all required clinical, administrative, and diagnosis information for initiation or continuation to Aetna Precertification Notification via phone or fax. Incomplete or illegible forms may delay review.

Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277

Documentation Required

Clinical documentation required

For initiation requests provide disease indication (colorectal cancer and specify clinical setting: unresectable/inoperable, advanced, metastatic, or other), prior cetuximab exposure/clinical failure, RAS (KRAS and NRAS) mutation status, BRAF V600E status, KRAS G12C status and requested regimen if positive, place in therapy (first-line or subsequent), tumor location/sidedness (colon and left-sided), prior chemotherapy, and planned regimen. For continuation requests provide date of last treatment and whether there is evidence of disease progression or unacceptable toxicity on the current regimen.

Billing Rule

Use Medicare form for MA Part B

For Medicare Advantage Part B members, providers must use the Medicare request form instead of this Aetna Vectibix precertification form.

Background / Notes

This precertification request form for Vectibix (panitumumab) is used in colorectal cancer and collects the clinical and administrative data Aetna requires to evaluate authorization requests but does not constitute the coverage policy itself. The form documents the required clinical fields for initiation (including indication, clinical setting, prior cetuximab failure, RAS/KRAS/NRAS mutation status, place in therapy, tumor sidedness, BRAF V600E status, KRAS G12C status and regimen, prior chemotherapy) and for continuation (date of last treatment and whether there is evidence of disease progression or unacceptable toxicity). It also captures patient demographics, insurance and member IDs, prescriber and dispensing/provider administration details (including administration CPT codes), product dose and frequency, diagnosis ICD codes, and a signature/acknowledgement statement regarding fraud and the possibility that the plan may request additional information.

OpenPayer

Vectibix (panitumumab) Injectable Medication Precertification Request

Summary

Coverage Stance

Clinical documentation requirements (Initiation & Continuation)

What providers must do

Codes referenced on form

Revision history

Background / Notes