CurrentCignaPolicy N/A

prior_authorization_request_form_denosumab

A Cigna prior authorization request form to collect clinical and administrative information for coverage review of denosumab products (Conexxence, Jubbonti, Prolia, Stoboclo) across multiple osteoporosis and bone-loss indications, including dispensing and sourcing options.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_denosumab

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; call for urgent requests to expedite.

POLICY UPDATE CHANGES

No material clinical/coverage changes noted.

9Listed diagnosis options

4Denosumab product options

12Oral bisphosphonate trial duration (months)

Policy overview and scope

This Cigna prior authorization request form collects required patient, prescriber, and clinical information to support authorization decisions for denosumab products (Conexxence, Jubbonti, Prolia, Stoboclo) across multiple indications, including postmenopausal and male osteoporosis, cancer therapy–related bone loss (androgen-deprivation or aromatase inhibitor therapy), glucocorticoid‑induced osteoporosis (GIO), and giant cell tumor of bone. The form asks for medication requested (product, dose, frequency, duration), ICD‑10 diagnosis selection, dispensing/source options (Accredo specialty pharmacy, prescriber office stock billed on medical claim, retail pharmacy, home health/home infusion vendor, or other), and intended use of the form to support prior authorization review.

Form completion and clinical information required for authorization review

Authorization will be reviewed when required fields and applicable clinical criteria are provided:

Mandatory patient and prescriber identifiers: Physician name, specialty, DEA/NPI/TIN, patient name, Cigna ID, date of birth, patient address, prescriber signature (asterisked items required for fax response)
Refer to form required fields
Medication requested identified (select one or more): Conexxence 60mg, Jubbonti 60mg, Prolia 60mg, Stoboclo 60mg; include dose, frequency, duration
ICD-10 diagnosis selection
- Diagnosis options
  - Diagnosis: Treatment of postmenopausal patients with osteoporosis
  - Diagnosis: Treatment of osteoporosis in men (to increase bone mass in men)
    Men defined by biological traits
  - Diagnosis: Treatment of bone loss in patients at high risk for fracture receiving androgen-deprivation therapy for nonmetastatic prostate cancer
  - Diagnosis: Treatment of bone loss in patients at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer
  - Diagnosis: Treatment of glucocorticoid-induced osteoporosis (GIO)
  - Diagnosis: Increase bone mineral density in patients with breast cancer
  - Diagnosis: Prevention of osteoporosis
  - Diagnosis: Giant cell tumor of the bone
  - Diagnosis: All other indications or diagnoses
Relevant clinical details
- Examples of required clinical details (select applicable)
  - Postmenopausal osteoporosis T-score: T-score ≤ -2.5 at lumbar spine, femoral neck, total hip and/or 33% radius (wrist) OR low bone mass (T-score between -1.0 and -2.5) with prescriber-assessed high fracture risk OR history of osteoporotic/fragility fractureT-score <= -2.5; low bone mass T-score between -1.0 and -2.5
  - Prior bisphosphonate trial: Documentation of trial and failure or intolerance to oral bisphosphonate therapy; if tried, inadequate efficacy defined after a trial duration of 12 months (examples: ongoing BMD loss, lack of BMD increase, or occurrence of osteoporotic/fragility fracture). IV bisphosphonate (zoledronic acid or ibandronate) trial also queried where applicableOral bisphosphonate trial duration 12 months
  - Oral bisphosphonate intolerance or inability: Significant intolerance (eg, severe GI or severe musculoskeletal adverse events), inability to swallow, inability to remain upright after dosing, or pre-existing GI condition (eg, esophageal lesions/ulcers, stricture, achalasia)
Source/location of medication specified: Specify where medication will be obtained: Accredo Specialty Pharmacy, prescriber office stock billed on medical claim, retail pharmacy, home health/home infusion vendor, or other
Accredo is Cigna's nationally preferred specialty pharmacy
Attestation and signature: Prescriber attestation that information is true and accurate and prescriber signature and date provided; plan may audit to verify accuracy
Fax or submit online; urgent requests require phone call

ref

This form is informational and is used to collect clinical and administrative data to support prior authorization decisions (coverage_stance: informational). Completed forms should be submitted using one of the methods listed under PROVIDER ACTIONS (fax to (855) 840-1678 or submit online via CoverMyMeds or SureScripts); urgent requests require a phone call to expedite.

Submission, documentation, and billing requirements

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. If the request is urgent, call the plan to expedite processing.

Documentation Required

Provide clinical documentation for diagnosis-specific criteria

Provide clinical documentation relevant to the selected diagnosis to support coverage review, including bone density and fracture history, prior therapy trials and outcomes, intolerance or inability to take oral bisphosphonates, renal function assessment, and status of concomitant cancer therapies as applicable.

T-score results
fracture history
prior bisphosphonate or IV bisphosphonate trials and outcomes (12 months trial duration)
intolerance details
renal function assessment
concomitant cancer therapy status

Billing Rule

Specify medication source and billing pathway

Indicate where the medication will be obtained: Accredo specialty pharmacy, prescriber's office stock (billing on a medical claim), retail pharmacy, home health/home infusion vendor, or other. Note that the selected source/billing pathway determines whether the claim is billed as a pharmacy or medical claim.

Billing pathway affects claim type (pharmacy vs medical)

Documentation Required

Attestation and signature required

The prescriber must attest that the information provided is true and accurate and must sign and date the form. The health plan or its designees may perform audits and request medical records to verify the information.

Definitions

Definitions (select)

Men (for policy purposes)Individuals with the biological traits of a man, regardless of gender identity or expression

High risk for fractureDetermined by the prescriber; form asks prescriber to attest whether patient is at high risk

The form’s clinical questions collect common coverage criteria domains needed for review, including documented T-score thresholds (for osteoporosis: ≤ -2.5 or low bone mass -1.0 to -2.5 with prescriber‑assessed high fracture risk or history of fragility fracture), documentation of prior bisphosphonate therapy or IV bisphosphonate trials and whether there was inadequate efficacy after a 12‑month trial or significant intolerance/ inability to take oral bisphosphonates, and renal considerations (for example, evaluation for CKD‑MBD if creatinine clearance <35 mL/min to reduce hypocalcemia risk).

OpenPayer

prior_authorization_request_form_denosumab

Policy overview and scope

Form completion and clinical information required for authorization review

Product selection options listed on form

Submission, documentation, and billing requirements

Definitions

Document revision history

Conexxence 60mg	Denosumab product name listed as selectable medication requested
Jubbonti 60mg	Denosumab biosimilar/product name listed as selectable medication requested
Prolia 60mg	Denosumab reference product listed as selectable medication requested
Stoboclo 60mg	Denosumab product name listed as selectable medication requested