CurrentCignaPolicy N/A

prior_authorization_request_form_unituxin

This document is a prior authorization request form used by Cigna for coverage review of Unituxin (dinutuximab). It collects patient, prescriber, clinical, and dispensing information to support new or continued therapy requests and specifies submission/fax instructions and urgency handling.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_unituxin

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; include all required asterisked fields and clinical support to avoid delay.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes documented for this form.

1Medication targeted by form

NeuroblastomaPrimary diagnosis option

5 business daysStandard response time

Quick Summary

This is a Cigna Pharmacy Services prior authorization form for Unituxin (dinutuximab). It is used to collect the clinical and administrative information required for coverage review and potential audit verification, including patient and prescriber details, diagnosis, therapy status, dose/frequency/duration, source of medication, and facility/billing information.

Authorization Data Elements / Clinical Questions

Form fields and required attestations to support PA request:

ALL of the following

Physician and office information: Physician's name (required fields marked with *)
Physician specialty: Specialty
Identifier: DEA, NPI or TIN (required if marked *)
Office contact person, phone, fax, and street address
Patient demographics: Patient name, Cigna ID, date of birth, phone, and street address
Urgency designation: Standard or Urgent (urgent requires attestation that standard review may seriously jeopardize the patient's life/health/function)
Medication details: Medication requested: Unituxin; dose, frequency, duration, and ICD-10 diagnosis code
Source of medication: prescriber's office stock, home health/home infusion vendor, or other (specify)
Dispensing facility: Facility/doctor dispensing and administering medication: facility name, tax ID, address, state
Chronic indication: Chronic/long-term condition indication: Yes/No
Diagnosis options: Diagnosis related to use: Neuroblastoma or Other (specify)
Therapy status: New therapy or Continued therapy (if continued, specify number of Unituxin cycles already received)
High-risk disease: Is disease high-risk? Yes/No
Prior chemotherapy response: Did patient receive chemotherapy as first-line therapy? (yes / no but received other therapy / no previous therapy received). If yes, did patient have partial or full response? Yes/No
Prior therapy details (if other)
Planned concurrent agents: Leukine (sargramostim), Proleukin (IL-2), isotretinoin (13-cis-retinoic acid) — options to indicate ALL or NONE
Additional clinical support: disease stage, prior therapy, performance status, names/doses/admin schedule of concurrent agents
Prescriber attestation and signature with date

What Providers Must Do

Prior Authorization

Submit prior authorization request

Fax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. Include all required asterisked fields and clinical support to avoid delays in review.

Prior Authorization

Urgent requests

If the request is urgent, call (800) 882-4462 to expedite the review. Selecting the Urgent checkbox requires attestation that applying the standard review time frame may seriously jeopardize the patient's life, health, or ability to regain maximum function.

Documentation Required

Clinical documentation required

Provide disease stage, prior therapy, performance status, number of prior Unituxin cycles (if continued therapy), and names, doses, and administration schedule of any concurrent agents to support medical necessity.

Billing Rule

Source and billing

Indicate where the medication will be obtained (prescriber's office stock billed on a medical claim form, home health/home infusion vendor, or other) and provide the facility or doctor dispensing/administration information including facility name and Tax ID for billing purposes.