CurrentCignaPolicy N/A

prior_authorization_form_sunlenca

A Cigna prior-authorization request form to collect patient, prescriber, clinical, and dispensing site information for requests to obtain Sunlenca (lenacapavir) via specialty pharmacy, retail, hospital outpatient, home infusion, or physician office dispensing. The form captures indication (HIV treatment or PrEP), treatment history/resistance, concurrent regimen, site of care, and urgency to support coverage review.

Policy Summary

PayerCigna

Policyprior_authorization_form_sunlenca

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 or SureScripts; urgent requests should be called to (800) 882-4462 for expedited review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this is an administrative prior authorization form to collect information for Sunlenca (lenacapavir) requests.

1Form for single drug (Sunlenca)

2Therapy status options

3Dispensing site choices

Policy summary and scope

This is a Cigna prior-authorization request form to collect patient, prescriber, clinical, and dispensing site information for requests to obtain Sunlenca (lenacapavir) via specialty pharmacy, retail, hospital outpatient, home infusion, or physician office dispensing. The form captures indication (HIV treatment or PrEP), treatment history/resistance, concurrent regimen, site of care, and urgency to support coverage review. Status: CURRENT; doc_type: other; payer: Cigna; policy id: prior_authorization_form_sunlenca.

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Information and clinical criteria collected for authorization

The form collects required items; approval decisions are based on the information provided and plan-specific coverage policies.

Patient identifiers and contact information must be provided for response (all items with * required).

Fax outcome cannot be returned unless all asterisked items are completed.

Medication requested: specify Sunlenca vial, J-code, directions, dose, quantity, and duration of therapy.

Specify where medication will be obtained (Accredo Specialty Pharmacy, hospital outpatient, retail pharmacy, home health/home infusion vendor, physician's office stock, other).

Accredo is Cigna's nationally preferred specialty pharmacy; ordering options provided.

Specify where drug will be administered (patient home, physician office, hospital outpatient, other).

Per some Cigna plans, infusion must occur in the least intensive, medically appropriate setting.

Indicate diagnosis related to use: HIV-1 infection treatment, or PrEP of HIV, or other indication (must specify).

Facility/doctor dispensing and administering medication details (facility name, tax ID, address) must be provided when applicable.

Questions on re-direction to alternate settings and home infusion candidacy; physician must provide medical necessity rationale if not appropriate.

Prescriber attestation and signature/date required acknowledging accuracy and permission for audit.

Therapy status (choose one)

Required provider steps and operational notes

Prior Authorization

Submit completed prior authorization form

Fax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests should be called to (800) 882-4462 for expedited review.

Documentation Required

Complete all required fields

All asterisked items must be completed to receive a faxed outcome; include clinical history (resistance, regimen failure, response metrics), dispensing site, administration site, and prescriber specialty/credentials.

Billing Rule

Preferred specialty pharmacy option

Medication may be obtained via Accredo (preferred specialty pharmacy) with ordering options provided; alternative procurement options must be specified.

Accredo (Cigna's nationally preferred specialty pharmacy)

Denial Risk

Incomplete form may delay or prevent coverage determination

Claims or authorization requests risk denial or delayed review if required clinical items, attestation, or contact information are missing.