CurrentCignaPolicy N/A

Taltz_Prior_Authorization_Form

A Cigna prior authorization form to request coverage/approval for Taltz (ixekizumab) including patient, prescriber, clinical, prior biologic trial, diagnosis, and dispensing site information to support a coverage decision.

Policy Summary

PayerCigna

PolicyTaltz_Prior_Authorization_Form

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.com or SureScripts; for urgent requests call (800) 882-4462 to expedite.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — the form content is informational and no substantive policy changes were provided.

5Indications listed on form

23Other biologics enumerated

5Standard response time (business days)

Taltz (ixekizumab) — Prior Authorization Form (Cigna)

This is a Cigna prior authorization form (V061020) to collect clinical and administrative information required to review requests for Taltz (ixekizumab), including patient and prescriber details, indication, prior biologic trials, and dispensing site information to support a coverage decision. The form requests medication details (dose, quantity, duration, J-code, frequency) and indication-specific data such as BSA for psoriasis and CRP/MRI findings for non-radiographic ankylosing spondylitis. Dispensing options include selection of Accredo Specialty Pharmacy, prescriber's office stock billed on a medical claim, retail pharmacy, home health/home infusion vendor, or other specified sources. Intended use: to provide the clinical and administrative data needed for prior authorization review of Taltz.

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Form Completion — Required Administrative & Patient Information

Form Completion / Information Required

Provide all starred (*) items and answer clinical questions to support prior authorization review.

ALL of the following

Physician Name (required if starred)
* Physician Name
Specialty
DEA, NPI or TIN (required if starred)
* DEA, NPI or TIN
Office Contact Person
Patient Name (required if starred)
* Patient Name
Cigna ID (required if starred)
* Cigna ID
Date of Birth (required if starred)
* Date of Birth
Patient Street Address (required if starred)
* Patient Street Address
Diagnosis related to use (must select at least one: ankylosing spondylitis, plaque psoriasis (CPP), non-radiographic ankylosing spondylitis, psoriatic arthritis, other)
Medication requested: indicate Taltz and provide dose, quantity, duration, J-code, frequency
Is this new start or continuation of therapy? (new start or continued therapy)

Urgency: Select urgency: Standard or Urgent (attest if urgent)

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form or submit online; for urgent (expedited) requests call the urgent phone number.

Fax: (855) 840-1678
Online: covermymeds.com or via SureScripts in your EHR
Urgent/expedited requests phone: (800) 882-4462

Continuation Requests — Response Documentation

Continued Therapy / Response Documentation

For continuation requests, document response and history:

Has patient had a good response to therapy (improvement or remission)?

Yes/No; if No provide clinical support for continued use

Provide dates patient has received Taltz

Document whether patient was previously approved by another health plan, has regular use >1 year, or restarting after a break

Documentation Required

Complete required clinical documentation

Include documentation of prior biologic therapies with dates and documented responses or intolerances; note any contraindications. For continuation requests provide dates of prior Taltz administration and evidence of clinical response. Include indication‑specific data such as body surface area (BSA) for psoriasis, CRP and sacroiliitis on MRI for non‑radiographic ankylosing spondylitis.

Prior biologic trials: drug names, dates taken, documented results (response, intolerance, failure)
Document any contraindications or why patient is not a candidate for listed biologics
For continuation: dates patient has received Taltz and whether they had a good response
Indication-specific: BSA for CPP; CRP and MRI sacroiliitis for non-radiographic AS

Concomitant or Other Biologic Use

Concomitant/Other Biologic Use

Describe patient's current/previous biologic therapy and rationale for combination if applicable.

Select applicable biologic use

Patient NOT taking any other biological and will not in future
Patient currently on another biological, will stop and start requested drug
Patient currently on another biological, and requested drug will be added (may continue both)
Patient currently on BOTH requested drug AND another biological
Other/unknown; provide drug name, dates, and clinical rationale for combined use
Include drug name, dates taken and clinical rationale if combining biologics

Prior Biologic Trials / Failures / Contraindications

Document trials, failures, inadequate response, intolerance, or contraindications to listed biologics.

ALL of the following

Documented failure/inadequate response/intolerance to any of the following (check all that apply)
- Actemra
- Cimzia
- Cosentyx
- Enbrel
- Entyvio

Indication-Specific Clinical Questions & Thresholds

Indication-Specific Questions

Additional data required varies by diagnosis.

ANY of the following

Ankylosing spondylitis (AS): Documentation of failure/inadequate response/intolerance OR contraindication OR not a candidate for at least one NSAID
Yes/No required
Non-radiographic ankylosing spondylitis: CRP elevated beyond upper limit of normal for reporting laboratory; Sacroiliitis reported on MRI
Yes/No
Chronic plaque psoriasis (CPP)
- Prior therapies tried or not candidate for: Systemic therapy (e.g., methotrexate, cyclosporine, Soriatane); Phototherapy (narrow/broad band UVB or PUVA); Topical therapy (e.g., coal tar, keratolytics, corticosteroids, anthralin, Dovonex, Tazorac); None of the above
Psoriatic arthritis (PsA): Documentation of failure/inadequate response/intolerance OR contraindication OR not a candidate for one DMARD (e.g., methotrexate, leflunomide, sulfasalazine)
Yes/No

Clinical Thresholds

Body Surface Area (BSA) threshold> 5% or < 5% with involvement of face, genitals, hands/feet, scalp, or intertriginous areas

CRP thresholdelevated beyond the upper limit of normal for the reporting laboratory

Codes & Billing Notes

J-CodeHCPCS

J-Code

Form requests J-code and frequency of administration; specific HCPCS code not provided on form

Billing Rule

Specify dispensing source

Indicate on the form where the medication will be obtained and select the appropriate dispensing source.

Accredo Specialty Pharmacy (nationally preferred specialty pharmacy)
Prescriber's office stock (billing on a medical claim form)
Retail pharmacy
Home Health / Home Infusion vendor
Other (specify)

Provider Responsibilities & Documentation Requirements

Documentation Required

Attestation and signature

Prescriber must attest that the information is true and accurate and must sign and date the form. The plan or its designees may perform routine audits and request medical records to verify the information provided.

Prescriber attestation is required
Prescriber signature and date required
Plan may audit and request medical records to verify reported information

Please complete all asterisked (*) items on the form — due to privacy regulations, Cigna will not return the outcome via fax unless all starred items are completed — and answer the required clinical questions so an authorization decision can be returned.

Term	Definition
BSA	Body Surface Area; affected BSA > 5% OR affected BSA < 5% with involvement of face, genitals, hands/feet, scalp, or intertriginous areas
CRP	C-reactive protein; documented as elevated beyond the upper limit of normal for the reporting laboratory

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