Cigna pemetrexed prior auth patient form

Coverage Criteria and Clinical Information

Information used for medical necessity determination

Authorization assessment will consider the following indication-specific information provided on the form

Indication selection: Provider must indicate the patient’s diagnosis from the listed cancer indications (e.g., bladder, cervical, epithelial ovarian, fallopian tube, leptomeningeal metastases from NSCLC, NSCLC, mesothelioma, non-nasopharyngeal head and neck cancer, PCNSL, primary peritoneal cancer, thymic carcinoma, vaginal cancer, or other)

see chunk 7

Prior chemotherapy status: Form captures whether the patient has received prior chemotherapy for the diagnosis and requests details about prior platinum-based regimens, number of cycles (including at least 4 cycles when applicable), and whether disease progression occurred after therapy

see chunks 8-9

Planned regimen and combinations: Form asks whether pemetrexed will be used as single-agent or in combination with pembrolizumab (Keytruda) and/or platinum-based chemotherapy to determine the appropriate treatment pathway

see chunks 8-9

Disease extent and performance status: Form requires disease stage (locally advanced, metastatic, recurrent, persistent), specific disease features (e.g., squamous vs non-squamous NSCLC), and performance status or KPS where applicable (e.g., PS 0-1 for non-nasopharyngeal head and neck cancer; KPS ≥60 for primary leptomeningeal treatment)

see chunks 9-11

Indication-specific questions: The form includes indication-specific items such as: for cervical/epithelial ovarian/fallopian tube/primary peritoneal cancers—whether disease is recurrent/persistent and single-agent use; for bladder/vaginal cancers—single-agent use and whether treatment is second-line or subsequent; for leptomeningeal NSCLC—EGFR mutation status and whether therapy is primary or maintenance with CSF cytology and clinical stability questions

see chunks 8,10,11

The form asks for the facility and/or doctor dispensing and administering medication including facility name, state, tax ID, and address. Note that per some Cigna plans, infusion of medication MUST occur in the lowest cost, medically appropriate setting; the form specifically asks whether the infusion is in a hospital outpatient–affiliated facility and whether the patient is a candidate for redirection to alternate settings (for example, AIS, MDO, or home) with assistance from a Specialty Care Option Case Manager. Providers should complete these fields to allow site-of-care review and potential redirection when applicable.

The form does not enumerate explicit items labeled “not medically necessary.” Instead it requires completion of all asterisked administrative fields (for example, physician identifiers and patient identifiers). Incomplete required information may prevent Cigna from responding via fax with the outcome of the review, so ensure all required fields marked with an asterisk are completed before submission to avoid delays or an inability to process the request.

Medication Request Options and Codes

Medication request optionsmixed

Pemfexy 500mg/20mL vial	Pemfexy 500mg/20mL vial
Pemetrexed 100mg/4mL vial	Pemetrexed 100mg/4mL vial
Pemetrexed 500mg/20mL vial	Pemetrexed 500mg/20mL vial
Pemetrexed 1gm/40mL vial	Pemetrexed 1gm/40mL vial

NDC/CPT notemixed

NDC/CPT not specified

Form lists medication vial strengths but does not list specific billing codes

Prior Authorization Steps and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — A prior authorization is required for pemetrexed (Pemfexy/pemetrexed). Fax the completed form to (855) 840-1678. If this is an URGENT request, call (800) 882-4462 (800.88.CIGNA). Save time by submitting online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Fax: (855) 840-1678
Urgent phone: (800) 882-4462
Online submission: www.covermymeds.com/main/prior-authorization-forms/cigna/

Documentation Required

Infusion site / setting

Infusion site / setting — Per some Cigna plans, infusion of medication must occur in the lowest cost, medically appropriate setting. If the infusion is occurring in a facility affiliated with a hospital outpatient setting, indicate whether the patient is a candidate for redirection to an alternate lower-cost setting (e.g., ambulatory infusion site, physician office, home) and provide medical necessity rationale if redirection is not appropriate.

Permitted Regimens and Usage Modalities

Regimen / Usage Modality	Relevant Form Questions / Required Details
{"text":"Pemetrexed as single-agent","status":""},{"text":"Form asks if medication is being given as single-agent therapy for relevant indications (e.g., bladder, vaginal, cervical, epithelial ovarian/fallopian tube/primary peritoneal, PCNSL, thymic); asks whether this is a new start, dose, duration, and if used as maintenance following prior chemotherapy","status":""}
{"text":"Pemetrexed in combination with pembrolizumab (Keytruda) only","status":""},{"text":"Form asks if pemetrexed will be used in combination therapy with Keytruda only; captures whether Keytruda was part of prior therapy, whether regimen is for maintenance (if prior chemo), disease stage (advanced/metastatic), and prior platinum exposure and cycle counts when applicable","status":""}
{"text":"Pemetrexed in combination with pembrolizumab (Keytruda) plus platinum-based chemotherapy","status":""},{"text":"Form includes option for use in combination with Keytruda and platinum-based chemotherapy (selected for no prior chemo); asks whether patient has metastatic disease and collects prior chemo/platinum details if prior therapy exists, including whether at least 4 cycles were given and if progression occurred","status":""}
{"text":"Pemetrexed in combination with platinum-based chemotherapy only","status":""},{"text":"Form captures use in combination with platinum-based chemotherapy only (option present for no prior chemo); asks whether disease is locally advanced or metastatic and requests prior platinum exposure and cycle/completion details when applicable","status":""}
{"text":"Pemetrexed for maintenance therapy following prior chemotherapy","status":""},{"text":"Form asks, when prior chemotherapy given and disease is advanced, whether pemetrexed will be used as maintenance therapy; also asks if prior therapy included platinum-based agents and if at least 4 cycles were received and whether disease progression occurred after 4 cycles","status":""}

Line of Therapy / Treatment Intent

Line of therapy

First-line: No prior chemotherapy for this diagnosis and pemetrexed will be used in combination (e.g., with pembrolizumab and platinum-based chemotherapy or with platinum-based chemotherapy alone) as initial therapy; when used first-line in combination with pembrolizumab plus platinum, form asks about metastatic disease status

see chunks 9

Continuation: Pemetrexed being given during an ongoing course of therapy (e.g., as part of combination regimens when prior chemotherapy was given and therapy is continuing); form captures whether Keytruda was part of initial therapy and whether platinum-based chemotherapy was part of first treatment and number of cycles

see chunks 8-9

Maintenance: Use of pemetrexed to maintain disease control after initial therapy (form asks if medication will be used as maintenance following prior chemotherapy or following Keytruda-based initial therapy); for leptomeningeal NSCLC maintenance, form requests negative CSF cytology or clinical stability with persistently positive CSF cytology

Biomarker and Test Results

inv-14: EGFR — mutation positive vs negative question on form

EGFR mutation statusForm asks whether patient with leptomeningeal metastases from NSCLC has EGFR mutation positive disease (Yes/No)

Use contextEGFR question is specific to leptomeningeal metastases from non-small cell lung cancer (NSCLC)

Decision roleEGFR positive vs negative status is collected to inform appropriateness of pemetrexed for primary or maintenance treatment in this indication

Definitions and Operational Terms

inv-11: Maintenance therapy — definition and whether pemetrexed will be used as maintenance following initial therapy

DefinitionMaintenance therapy: use of the medication after initial (prior) chemotherapy to maintain disease control; the form asks whether pemetrexed will be used as maintenance following prior chemotherapy

Form questionFor prior chemotherapy and advanced disease (including when Keytruda was part of initial therapy), the form asks explicitly: 'Will/Is this medication be(ing) used as maintenance therapy? (Yes/No)'

Contexts collectedMaintenance status is captured across indications when prior chemo was given (e.g., NSCLC, cervical when advanced, and settings with prior Keytruda), and is used together with prior platinum exposure and cycle count to characterize therapy intent

Required supporting detailsWhen maintenance is indicated, the form also collects disease status (advanced/metastatic), prior platinum use, number of cycles, and progression after therapy to support the maintenance designation

inv-12: Infusion site of care — definition and question about hospital outpatient affiliation and candidacy for alternative settings

Background and Clinical Context

Pemetrexed is an antimetabolite chemotherapy agent used across multiple solid tumor indications captured on the form, including non–small cell lung cancer, mesothelioma, epithelial ovarian and related gynecologic cancers, and others. The intake form collects indication-specific clinical details—such as prior chemotherapy and platinum exposure, whether pemetrexed will be given as single-agent therapy or in combination with pembrolizumab and platinum chemotherapy, disease stage, performance status, and whether it will be used as maintenance therapy—to support the medical necessity assessment.

OpenPayer

Pemetrexed (Pemfexy/Pemetrexed) prior authorization patient information form

Coverage Criteria and Clinical Information

Medication Request Options and Codes

Prior Authorization Steps and Provider Requirements

Permitted Regimens and Usage Modalities

Line of Therapy / Treatment Intent

Biomarker and Test Results

Definitions and Operational Terms

Background and Clinical Context