CurrentCignaPolicy N/A

prior_authorization_request_form

A Cigna prior authorization request form to request coverage/authorization for subcutaneous ustekinumab products (Otulfi, Pyzchiva, Stelara, Ustekinumab SC) across multiple indications (Crohn's disease, ulcerative colitis, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis). It collects patient, provider, dosing, dispensing site, indication-specific clinical questions, and documentation attestation.

Policy Summary

PayerCigna

Policyprior_authorization_request_form

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts and attach all required patient-specific documentation to avoid denial.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an unchanged administrative prior authorization form.

5Indications listed on form

4Ustekinumab product choices listed

5Standard response time (business days)

Policy overview and purpose

This is a Cigna prior authorization request form to request coverage/authorization for subcutaneous ustekinumab products including Otulfi, Pyzchiva, Stelara, and Ustekinumab SC. The form collects required patient and provider information, urgency designation, medication selection (dose, quantity, duration, frequency, J‑Code, ICD‑10), dispensing/administration site, and patient weight.

Form submission, documentation & billing actions

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via covermymeds.com or SureScripts. Be sure to complete all required asterisked (*) patient and provider fields and attach patient-specific documentation to avoid denial.

Prior Authorization

Urgent requests

For urgent requests, call (800) 882-4462 to expedite the review. Our standard response time for prescription drug coverage requests is 5 business days.

Documentation Required

Attach supporting clinical documentation

Attach supporting patient-specific clinical documentation such as chart notes, laboratory results, medical tests, claims records, and prescription receipts to document prior trials, intolerances, and clinical response.

Chart notes
Laboratory results
Medical test results
Claims records
Prescription receipts

Billing Rule

Specify dispensing site and billing method

Indicate where the medication will be obtained and how it will be billed (examples: Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, or Physician's office stock). The selected dispensing/administration site affects how the medication is obtained and billed.

Accredo Specialty Pharmacy
Hospital Outpatient
Retail pharmacy
Home Health / Home Infusion vendor
Physician's office stock (billing on a medical claim form)

The prescriber must attest that the information provided is true and accurate to the best of their knowledge and acknowledge that the Health Plan or its designees may perform a routine audit and request medical information to verify accuracy. A prescriber signature and date are required on the form.

Medication choices, dosing, dispensing and code entry

Medication selection and logistics

Complete the following to specify medication selection, dosing, duration, coding, patient weight, and dispensing/administration site.

ALL of the following

Medication requested: select product (Otulfi 45 mg/0.5 mL; Pyzchiva 45 mg/0.5 mL; Stelara 45 mg/0.5 mL; Ustekinumab 45 mg/0.5 mL; Other — specify)
Ensure product matches submitted J-code and NDC if applicable.
Dose and quantity: provide strength, number of vials/syringes per dose and total quantity requested
Example: 45 mg (0.5 mL) — 1 vial per dose, quantity 4.
Duration of therapy: state the requested coverage period (for example, 3 months, 6 months, 12 months)
Align duration with expected administration frequency.
Frequency of administration: specify induction and maintenance schedule (e.g., single IV induction then SC maintenance q8–12 weeks)
If an IV induction is required (Crohn's), indicate date administered or planned within 2 months of SC start.
J-Code: provide the HCPCS J-code associated with the product (enter J-code exactly)
If billing under NDC or pharmacy benefit, indicate accordingly.
ICD-10 code: provide primary diagnosis code supporting the request
Must match clinical indication selected elsewhere on the form.
Patient weight: provide current weight in kg or lb
Required for weight-based dosing where applicable.
Dispensing / Administration site (select one or more):
- Accredo Specialty Pharmacy (Cigna’s nationally preferred specialty pharmacy)
  If selected, include pharmacy order information or e-prescribe details.
- Hospital Outpatient
  Provide facility name, Tax ID, and address in Facility block.
- Retail pharmacy
  Provide NPI/TIN and dispensing pharmacy details if applicable.
- Home Health / Home Infusion vendor
  Provide vendor name and contact details; include infusion plan.
- Physician's office stock (billing on a medical claim form)
  Provide facility/physician Tax ID and indicate billing intent.

Product / J-code entrymixed

J-Code	Provide the HCPCS J-code for the medication (enter exact J-code)
ICD10	Provide the ICD-10 diagnosis code supporting the request

Form completion and urgency

Form completion and urgency: the following items are required for processing. If any starred (*) fields are missing, Cigna will be unable to respond via fax with the outcome.

ALL of the following

Complete all required patient and provider fields marked with an asterisk (*) including Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, and Patient Street Address.
Fax completed form to: (855) 840-1678. If this is an URGENT request, call (800) 882-4462 (800.88.CIGNA).
Checking 'Urgent' attests that standard review time may seriously jeopardize the patient's life, health, or ability to regain maximum function.

Attestation and documentation

Attestation and documentation: the prescriber must attest to statements below and attach supporting documentation where indicated.

ALL of the following

Prescriber attestation: by submitting this form the prescriber attests that the information provided is accurate and complete to the best of their knowledge.
For product-specific required trials or exceptions (for Otulfi/Pyzchiva/Stelara/Ustekinumab), indicate whether supporting documentation of prior trials or formulation-related intolerance is attached.
Documentation may include chart notes, lab results, test results, claims records, prescription receipts, or other patient-specific records. Lack of documentation may result in denial.
If the request involves inability to use Preferred medications due to differences in inactive ingredients causing significant allergy or serious adverse reaction, attach clinical documentation describing the allergy/intolerance and rationale.
Specify which preferred agents were tried and why they cannot be used.

Definitions

BiologicIncludes listed biologic products such as adalimumab products, Bimzelx, Cimzia, Cosentyx, etanercept products, Entyvio, Ilumya, infliximab products, Kevzara, Kineret, Omvoh, Orencia, rituximab products, Skyrizi, Siliq, Simponi, Taltz, tocilizumab products, Tremfya, an ustekinumab product, or Zymfentra.

This authorization request form is used by Cigna Pharmacy Services to collect the clinical and administrative information required to evaluate coverage for subcutaneous ustekinumab products and related agents.

It requests indication‑specific prior therapy history and duration, objective measures of response (for example, fecal or serum markers, imaging, endoscopy, BSA/erythema/induration for psoriasis, or standardized PsA activity scores), confirmation that the prescriber is the appropriate specialist or consulted (gastroenterologist, dermatologist, or rheumatologist as applicable), and specific documentation of prior trials or formulation‑related intolerances.

The form instructs providers to attach patient‑specific documentation (chart notes, laboratory results, medical tests, claims records, prescription receipts, or other identifying information) to support prior trials, intolerances, and clinical response; failure to attach required documentation may result in denial. Submission instructions include faxing to (855) 840-1678 or submitting online, with urgent requests handled by phone.

OpenPayer

prior_authorization_request_form

Policy overview and purpose

Form submission, documentation & billing actions

Medication choices, dosing, dispensing and code entry

Documentation requirements for product substitution and preferred agents

Indication-specific clinical questions used to support authorization

Definitions