CurrentCignaPolicy N/A

Cosela (trilaciclib) prior authorization

This document is a Cigna prior-authorization request form for Cosela (trilaciclib) used primarily in small cell lung cancer to reduce chemotherapy-induced myelosuppression; it governs what providers must submit when requesting coverage and affects prescribers, dispensing facilities, and Cigna review staff.

Policy Summary

PayerCigna

PolicyCosela (trilaciclib) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form (fax or online) including diagnosis, stage, chemotherapy regimen, dose/frequency/duration, co-administration with G-CSF/ESA, and prescriber attestation/signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

855-840-1678fax number to submit completed form

800-882-4462phone number for urgent requests

v011525form/version identifier

Coverage Criteria for Cosela (trilaciclib)

Information required for review

Authorization requests for Cosela will be reviewed when the following clinical information is provided:

Primary criteria: Provider has completed required patient and prescriber identification; provided diagnosis (SCLC or other); indicated if ES-SCLC; stated chemotherapy regimen (platinum + etoposide OR topotecan when applicable); provided dose, frequency, duration, and whether this is a new start or continued therapy; attested and signed form.

All items marked with * on the form must be completed.

Regimen options: Patient will be receiving either a platinum (carboplatin or cisplatin) plus etoposide-containing regimen OR a topotecan-containing regimen.

Form asks conditional questions depending on diagnosis and regimen.

The prior authorization form asks whether the requested medication is for a chronic or long-term condition by including the question: “Is the requested medication for a chronic or long-term condition for which the prescription medication may be necessary for the life of the patient?” Providers must indicate Yes or No on the form; the form does not list any explicit coverage exclusions associated with that response.

Policy Summary

PayerCigna

PolicyCosela (trilaciclib) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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What Providers Must Submit

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must be submitted using the Cigna prior authorization form (fax or online) and include clinical details including diagnosis, disease stage (if small cell lung cancer), and the planned chemotherapy regimen.

Submit via fax using the Cigna Cosela prior authorization form or online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.
Standard response time: 5 business days; if urgent, call to expedite.

Step Therapy

Step Therapy / Co‑administration Note

The form asks whether Cosela will be co‑administered with a granulocyte‑colony stimulating factor (G‑CSF) or an erythropoiesis‑stimulating agent (ESA) and whether the request is for reduction of chemotherapy‑induced myelosuppression. Provide responses to these step therapy / co‑administration items on the form.

Documentation Required

Required Documentation on Form

Complete all required patient and prescriber identifiers on the form. Asterisked (*) items (e.g., physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, patient address) must be filled in. Include the diagnosis (specify if SCLC and stage), planned chemotherapy regimen (agents, doses, schedule), and relevant clinical details (disease stage, prior therapy, performance status).

Denial Risk

Incomplete Form Risk

Incomplete required patient or provider identification fields (asterisked items) will prevent the reviewer from responding via fax and may delay processing of the request. Ensure all mandatory fields are completed to avoid processing delays.

Definitions

ES-SCLC — Extensive-stage small cell lung cancer (ES-SCLC) indication

DefinitionExtensive-stage small cell lung cancer (ES-SCLC)

Document contextForm asks the provider to indicate whether the patient has extensive-stage disease (question: 'Does your patient have extensive-stage disease (ES-SCLC)?').

Conditional fieldsSeveral subsequent form questions (intended use, chemotherapy regimen, first cycle, oncologist involvement) are asked only if SCLC/ES-SCLC is indicated.

Purpose of Cosela — use to decrease the incidence of chemotherapy-induced myelosuppression

Primary purposeUse to decrease the incidence of chemotherapy-induced myelosuppression (form asks: 'Is this medication being used to decrease the incidence of chemotherapy-induced myelosuppression?').

Clinical contextIntended for patients receiving specified SCLC chemotherapy regimens (platinum + etoposide or topotecan) as documented on the form.

Co-administrationForm queries whether Cosela will be co-administered with a G-CSF or an erythropoiesis‑stimulating agent (ESA).

Regimen	Intended effect / Indication	Coverage status
Platinum (carboplatin or cisplatin) + etoposide-containing regimen	Decrease incidence of chemotherapy-induced myelosuppression in patients receiving specified chemotherapy regimens for SCLC	Covered with criteria
Topotecan-containing regimen	Decrease incidence of chemotherapy-induced myelosuppression in patients receiving specified chemotherapy regimens for SCLC	Covered with criteria

OpenPayer

Cosela (trilaciclib) prior authorization

Coverage Criteria for Cosela (trilaciclib)

Requested Medication and Codes

What Providers Must Submit

Background

Definitions

Line of Therapy

Covered Chemotherapy Regimens