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Opdualag Medication Precertification Request
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Aetna precertification request form to collect patient, prescriber, dispensing, diagnosis, and clinical information required for prior authorization of Opdualag (nivolumab and relatlimab-rmbw) therapy, including start or continuation details and clinical justification for infusion setting.
No material clinical/coverage changes — form remains an informational precertification request to collect required documentation.
Opdualag precertification request — at a glance
Scope: This is an Aetna precertification/authorization request form to collect patient, prescriber, dispensing, product, diagnosis, and detailed clinical information required for prior authorization of Opdualag (nivolumab and relatlimab-rmbw) infusion therapy, including start or continuation details and clinical justification for the infusion setting. Background/Status: The form is current and must be completed and submitted with all required clinical documentation prior to treatment initiation or for continuation requests; Aetna may request additional information and may deny or delay coverage if required information is not provided. Subject: Opdualag (nivolumab and relatlimab-rmbw) precertification request form. Definitions: Opdualag — Brand name for combination nivolumab and relatlimab-rmbw. Use: This Aetna form is used to collect administrative, prescriber, dispensing, diagnosis, and clinical information to support approval decisions for infusion therapy.
Required clinical information for precertification
Required Clinical Information for Precertification
Form fields to be completed for all precertification requests and continuation requests; must provide clinical documentation.
ALL of the following
- Indication: Melanoma (checkbox)
Clinical setting (select one or more)
- Unresectable disease
- Metastatic disease
- Other
- Continuation request — disease progression/toxicity: For continuation requests: specify if there is evidence of disease progression or unacceptable toxicity while on current regimen (Yes/No)
- Continuation request — outpatient hospital setting: For continuation requests: indicate if infusion request is in an outpatient hospital setting (Yes checkbox)
- Continuation request — maintenance regimen: For continuation requests: indicate if patient is continuing on a maintenance regimen that includes provider administered combination chemotherapy and specify regimen (Yes/No)
- Severe toxicity requiring continuous monitoring: Document severe toxicity requiring continuous monitoring (examples listed) (Yes/No) and explanation if Yes
- Adverse events unresponsive or severe infusion reactions: Document adverse events with requested product unresponsive to conventional interventions or severe infusion reactions (Yes/No) and explanation if Yes
- Severe venous access issues: Document severe venous access issues requiring special interventions available only in outpatient hospital setting (Yes/No) and explanation if Yes
- Behavioral/caregiver limitations: Document significant behavioral issues and/or physical or cognitive impairment that impact infusion safety AND lack of caregiver (Yes/No) and explanation if Yes
- Medical instability: Document if patient is medically unstable (respiratory, cardiovascular, renal conditions) limiting tolerance of large volume/load or predispose to severe adverse event that cannot be managed in alternate setting (Yes/No) and provide description
- Treatment duration: Indicate if patient is within initial 6 months of starting therapy (Yes/No) and number of continuous months of treatment
Codes and billing fields on the form
| Primary ICD Code | Placeholder field for primary diagnosis ICD code (melanoma or other) |
| Secondary ICD Code | Placeholder field for secondary diagnosis ICD code |
| Other ICD Code | Placeholder field for other applicable ICD codes |
| Administration code(s) (CPT) | Field for provider to enter appropriate infusion/administration CPT code(s) |
What providers must do
Precertification submission required
Providers must complete and submit this precertification request form with all required clinical documentation for Opdualag prior to treatment initiation or for continuation requests.
Clinical documentation required
Providers must document indication (melanoma), clinical setting (unresectable/metastatic/other), toxicities, adverse events, venous access issues, behavioral/caregiver limitations, medical instability, and duration on therapy as applicable.
- Indication
- Clinical setting
- Toxicities
- Adverse events
- Venous access issues
- Behavioral/caregiver limitations
- Medical instability
- Duration on therapy
Use Medicare form for Medicare Advantage Part B
For Medicare Advantage Part B members, providers must use the Medicare request form instead of this form.
Incomplete forms may delay or prevent approval
All fields must be completed and legible; Aetna may request additional information and may deny or delay coverage if required information is not provided.
Background and definitions
This two-page Aetna medication precertification request form is used to collect administrative, insurance, prescriber, dispensing, product, diagnosis, and detailed clinical information to support approval decisions for Opdualag (nivolumab and relatlimab-rmbw) infusion therapy. Special considerations: the form captures outpatient hospital administration needs (questions about whether the infusion request is in an outpatient hospital setting, severe toxicity requiring continuous monitoring, severe venous access issues requiring interventions only available in an outpatient hospital, medical instability, and caregiver/behavioral limitations) to document when outpatient hospital resources are required.
Opdualag — Brand name for combination nivolumab and relatlimab-rmbw.
Document revision history
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.