CurrentAetnaPolicy N/A

Cosela (trilaciclib) Medication Precertification Request — Coverage Criteria

This form governs precertification requests to Aetna for Cosela (trilaciclib) used to reduce chemotherapy-induced myelosuppression in patients (notably with extensive-stage small cell lung cancer). It affects prescribers, dispensing providers, and administrative staff submitting prior authorization information.

Policy Summary

PayerAetna

PolicyCosela (trilaciclib) Medication Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed precertification form including patient, prescriber, dosing, primary ICD code, chemotherapy regimen and timing (within 4 hours) via Aetna Precertification Notification (phone/fax).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 pageform length

Extensive-stage SCLCindication

4 hourstiming req

Aetna Precertcontact

Coverage Criteria

Policy Summary

PayerAetna

PolicyCosela (trilaciclib) Medication Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Required documentation and clinical items: 1) Patient identifying information and insurance details are provided on the form; 2) Prescriber and dispensing provider information are provided; 3) Product name: Cosela (trilaciclib) with dose and frequency specified; 4) Primary ICD code provided (form references extensive-stage small cell lung cancer) and any secondary/other ICD codes as applicable; 5) Clinical indication: medication is being used to decrease the incidence of chemotherapy-induced myelosuppression (Yes/No checkbox completed); 6) Chemotherapy regimen specified (Platinum/etoposide, Topotecan, or Other); 7) Trilaciclib administration timing: checkbox indicating it will be given within 4 hours prior to the start of chemotherapy on each chemotherapy day; 8) Documentation whether the medication will be used with G-CSF or ESAs during cycle 1; 9) For start of treatment or continuation requests, the appropriate date fields are completed (start date or date of last treatment).

This form collects the items Aetna requires to evaluate medical necessity; it does not state explicit approval criteria or coverage limits.

Coding

Administration CPT CodesCPT

Administration code(s) (CPT)

Administration CPT codes to be provided by requester

Diagnosis CodesICD-10

Primary ICD Code	Primary diagnosis ICD code to be provided
Secondary ICD Code	Secondary diagnosis ICD code to be provided
Other ICD Code	Other diagnosis ICD code to be provided

inv-06: Timing before chemotherapy

Timing relative to chemotherapyTrilaciclib must be administered within 4 hours prior to the start of chemotherapy on each day chemotherapy is administered.

Per-request confirmationForm contains a checkbox question: 'Will the requested drug be given within 4 hours prior to the start of chemotherapy on each day chemotherapy is administered?' (Yes/No).

Applies toEach day chemotherapy is administered (required for every cycle day when trilaciclib is used).

Provider Actions & Administrative Requirements

Prior Authorization

Precertification required

Precertification through Aetna is required for Cosela (trilaciclib). Use the Aetna Precertification Notification contact (phone/fax) and submit a completed, legible Cosela (trilaciclib) Medication Precertification Request form. Include whether this is start of treatment or continuation and the requested dates.

Aetna Precertification Notification phone: 1-866-752-7021 (TTY: 711); fax: 1-888-267-3277
For Medicare Advantage Part B: use the Medicare Request Form

Documentation Required

Concomitant therapy documentation

The precertification form asks whether Cosela will be used with G-CSF or ESAs during cycle 1. Document the planned use (Yes/No) for: granulocyte colony-stimulating factor (G-CSF) as primary prophylaxis during cycle 1 and erythropoiesis-stimulating agents (ESAs) as primary prophylaxis during cycle 1. The form does not require prior failure of these agents before Cosela use, but clear documentation of concomitant therapies is required.

Will Cosela be used with G-CSF as primary prophylaxis during cycle 1? (Yes/No)
Will Cosela be used with ESAs as primary prophylaxis during cycle 1? (Yes/No)

Documentation Required

Required documentation for precertification

Complete and legible patient, prescriber, dispensing provider, product, and diagnosis information must be provided on the precertification request. Required items include patient demographics and contact information, prescriber name/license/NPI, specialty, product name (Cosela/trilaciclib), dose and frequency, indication (extensive-stage small cell lung cancer), primary ICD code and any secondary codes, chemotherapy regimen, whether drug will be given within 4 hours prior to chemotherapy, and signature/date. Missing or illegible information may delay or result in denial of the request.

Patient information: name, DOB, contact, height/weight, allergies
Prescriber information: name, credentials, address, phone, NPI, state license, specialty
Product information: Cosela (trilaciclib) — dose and frequency
Diagnosis: primary ICD code (extensive-stage small cell lung cancer) and any additional codes
Clinical information: chemotherapy regimen, timing (within 4 hours prior to chemo), planned use with G-CSF/ESAs, signature and date

Denial Risk

Fraudulent information risk

Providing materially false information or concealing material information on the precertification request is a fraudulent insurance act and may lead to denial and criminal/civil penalties. The plan may request additional information or clarification to evaluate requests.

Request completed by: signature and date required
Fraudulent information or concealment may result in denial and legal penalties
Plan may request additional information to evaluate the request

Background

This precertification form is for requests for Cosela (trilaciclib) to reduce chemotherapy‑induced myelosuppression. The form specifically references the indication extensive‑stage small cell lung cancer and requires documentation that the medication is being used to decrease the incidence of chemotherapy‑induced myelosuppression. The form asks the provider to specify the chemotherapy regimen (platinum/etoposide, topotecan, or other) and to confirm that trilaciclib will be administered within 4 hours prior to the start of chemotherapy on each day chemotherapy is administered. It also asks whether the drug will be used with G‑CSF or erythropoiesis‑stimulating agents (ESAs) as primary prophylaxis during cycle 1.

Initial Therapy Criteria

Initial therapy documentation

Initial therapy requests must indicate start date and complete clinical information.

Initial request items: Check 'Start of treatment' and provide start date; specify product (Cosela/trilaciclib) dose and frequency; indicate clinical indication (decrease incidence of chemotherapy-induced myelosuppression) and select the chemotherapy regimen (Platinum/etoposide, Topotecan, or Other); confirm planned timing that trilaciclib will be administered within 4 hours prior to the start of chemotherapy on each chemotherapy day; document whether G-CSF or ESAs will be used as primary prophylaxis during cycle 1.

Form includes specific fields for start date, product dose/frequency, indication, regimen, timing, and concomitant prophylactic agents.

Continuation Therapy Criteria

Continuation therapy documentation

Continuation requests require date of last treatment and completion of the same clinical fields as initial requests.

Continuation request information: Select 'Continuation of therapy' and provide the date of last treatment; repeat required clinical information including product dose/frequency, clinical indication, chemotherapy regimen, confirmation of timing (within 4 hours prior to chemotherapy on each chemotherapy day), and documentation of use with G-CSF or ESAs if applicable.

Form includes a checkbox for 'Continuation of therapy' and requests date of last treatment; same clinical fields as initial request must be completed.

Step Therapy

Step	Form query	Requirement / edit
1	Will the requested medication be used with a granulocyte colony-stimulating factor (G-CSF) as primary prophylaxis during cycle 1? (Yes/No)	Documented on precertification form; no step edit or prior failure of other therapies required.
2	Will the requested medication be used with erythropoiesis-stimulating agents (ESAs) as primary prophylaxis during cycle 1? (Yes/No)	Documented on precertification form; no step edit or prior failure of other therapies required.

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