CurrentCignaPolicy N/A

Oncology (Injectable) - Cosela

This Cigna Coverage Policy governs prior authorization and medical necessity criteria for Cosela (trilaciclib IV) when used to decrease chemotherapy-induced myelosuppression in adults with extensive-stage small cell lung cancer; it applies to benefit plans administered by Cigna Companies.

Policy Summary

PayerCigna

PolicyOncology (Injectable) - Cosela

Policy CodePolicy N/A

Change TypeMaterial revision (name change and criteria updates)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that Cosela is prescribed by or in consultation with an oncologist and that all coverage criteria for extensive-stage SCLC are met.

SourceLink

POLICY UPDATE CHANGES

Policy name changed from 'Trilaciclib Injection' to 'Oncology (Injectable) - Cosela' and dosing information for small cell lung cancer was added.

Criterion added that during the first cycle of chemotherapy, Cosela will not be co-administered with a colony stimulating factor (G-CSF) or an erythropoiesis-stimulating agent (ESA), per the prescriber.

240 mg/m2dose per infusion

6 monthsstandard approval

J1448HCPCS

Adults ≥18age requirement

Coverage Criteria for Cosela (trilaciclib)

FDA-Approved Indication (Small Cell Lung Cancer)

Approve for 6 months if the patient meets ALL of the following (A–F):

FDA-Approved Indication for Cosela

A) Patient is ≥ 18 years of age;
B) Patient has extensive-stage disease;
C) The medication is used to decrease the incidence of chemotherapy-induced myelosuppression;
D) Patient meets ONE of the following:
- i. Patient will be receiving a platinum (carboplatin or cisplatin) plus etoposide-containing chemotherapy regimen (with or without immune checkpoint inhibitor).

Policy Summary

PayerCigna

PolicyOncology (Injectable) - Cosela

Policy CodePolicy N/A

Change TypeMaterial revision (name change and criteria updates)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that Cosela is prescribed by or in consultation with an oncologist and that all coverage criteria for extensive-stage SCLC are met.

SourceLink

On This Page

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Regimen	Intended use / notes
Administer prior to each day chemotherapy is given with a platinum (carboplatin or cisplatin) + etoposide-containing regimen (with or without an immune checkpoint inhibitor)
Administer prior to each day chemotherapy is given with a topotecan-containing regimen

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization is required for Cosela. All approvals are provided for the duration noted (e.g., 6 months for the FDA indication). Because of the specialized skills required for evaluation and monitoring, Cosela must be prescribed by or in consultation with a physician who specializes in the condition being treated (oncologist).

Prior authorization required for prescription benefit coverage of Cosela.
Approvals are issued for the duration noted; when authorized in months, 1 month = 30 days.

Note

Prescriptions must be written by or in consultation with an oncologist.

Documentation Required

Provider and Documentation Requirements

Documentation must support that the patient meets the FDA‑approved indication and all listed criteria for Small Cell Lung Cancer (age ≥18; extensive‑stage disease; use to decrease chemotherapy‑induced myelosuppression; receiving an eligible chemotherapy regimen [platinum + etoposide OR topotecan]; not coadministered with a G‑CSF or ESA during the first chemotherapy cycle). Approvals are for 6 months when criteria are met. Dosing: approve one dose (240 mg/m2) IV infusion for every day the chemotherapy regimen is given. Receipt of sample product does not satisfy coverage criteria.

Patient must be ≥ 18 years of age.
Patient must have extensive‑stage small cell lung cancer.
Used to decrease incidence of chemotherapy‑induced myelosuppression.
Patient will receive either: (i) a platinum (carboplatin or cisplatin) + etoposide regimen, OR (ii) a topotecan‑containing regimen.
During the first cycle of chemotherapy, Cosela will not be coadministered with a granulocyte‑colony stimulating factor (G‑CSF) or an erythropoiesis‑stimulating agent (ESA).
Medication prescribed by or in consultation with an oncologist.
Approve for 6 months when all criteria are met.
Dosing: 240 mg/m2 IV infusion — one dose for every day the chemotherapy regimen is given.

Denial Risk

Denial Triggers

Claims submitted without covered diagnosis/procedure codes or that do not follow the policy criteria will be denied as not covered. Requests not meeting the FDA‑approved criteria for Cosela (see documentation requirements) will be denied.

Claims not accompanied by covered codes under the applicable Coverage Policy will be denied as not covered.
Failure to document compliance with all approval criteria (including prescriber specialty and regimen details) is a denial trigger.

C9078	Injection, trilaciclib, 1 mg (Code deleted 09/30/2021)
J1448	Injection, trilaciclib, 1 mg

OpenPayer

Oncology (Injectable) - Cosela

Coverage Criteria for Cosela (trilaciclib)

Coding and Dosing

Provider Actions, Authorization, and Documentation

Supportive / Prophylactic Use with Chemotherapy

Regimens Where Cosela Is Used Prophylactically

Definitions

Background