CurrentCignaPolicy N/A

prior_authorization_request_form_kadcyla

Prior authorization request form for Kadcyla (trastuzumab emtansine) to be completed by prescribers submitting coverage requests to Cigna. Captures patient, prescriber, clinical indication and treatment details to support utilization review and site-of-care decisions.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_kadcyla

Policy CodePolicy N/A

Change TypeInformational form (no coverage policy changes)

Effective Date

Next Review Date

Key ActionComplete all asterisked (*) items on the form and include clinical details, diagnosis, prior therapies, and prescriber attestation/signature before faxing or submitting online.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

1Form version

Policy overview

This is a prior authorization request form for Kadcyla (trastuzumab emtansine) to be completed by prescribers submitting coverage requests to Cigna. The form captures patient and prescriber identification, urgency, the medication requested (dose, frequency, duration, start date, new start, patient weight), diagnosis (ICD-10), medication sourcing, facility/dispensing and administration details, and disease-specific clinical information to support utilization review and site-of-care decisions.

Key details

Form completion & clinical questions

Form completion / clinical questions

Form collects required clinical and administrative information to support a prior authorization review; completion of all fields marked with * is required for response via fax.

ALL of the following

Patient and prescriber identification fields completed for all asterisked items (Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address).
Refer to asterisked fields; response via fax limited unless completed.
Urgency selection: Specify urgency: Standard or Urgent (urgent requires attestation that standard review may seriously jeopardize patient).
Medication details: Medication requested: Kadcyla; provide dose, frequency, duration, start date, whether new start, and patient weight.
Diagnosis code: Provide ICD-10 diagnosis code.
Medication source/vendor: Indicate source/vendor of medication (Accredo Specialty Pharmacy, prescriber's office stock billed on medical claim, retail pharmacy, home health/home infusion vendor, other).
Accredo is Cigna's nationally preferred specialty pharmacy; ordering details provided.
Facility/dispensing details: Provide facility and/or doctor dispensing and administering medication details including facility name, tax ID, address; note that some Cigna plans require infusion in the lowest cost medically appropriate setting.
Site-of-care questions: Answer site-of-care questions: whether infusion occurs in hospital outpatient affiliated facility and whether candidate for re-direction to alternate setting; candidacy for home infusion; whether physician has in-office infusion site.
Chronic/long-term indication: Indicate if medication is for a chronic/long-term condition requiring life-long therapy (Yes/No).
Diagnosis category selection: Select diagnosis category: early breast cancer (EBC), breast cancer, non-small cell lung cancer (NSCLC), salivary gland tumors of head and neck, or other (specify).
Disease-specific clinical items (answer applicable boxes)
- HER2-positive disease: For breast cancer or salivary gland tumors: indicate HER2-positive disease (Yes/No).
- EBC adjuvant use: For EBC: indicate adjuvant use (Yes/No).
- EBC residual invasive disease: For EBC: indicate evidence of residual invasive disease after neoadjuvant therapy (Yes/No).
- EBC prior taxane+Herceptin neoadjuvant: For EBC: indicate prior receipt of taxane and Herceptin-based neoadjuvant therapy (Yes/No).
- Recurrent or metastatic disease: For breast cancer (not EBC) or salivary gland tumors: indicate recurrent or metastatic disease (Yes/No).
Additional pertinent information: Provide additional pertinent information including disease stage, prior therapy, performance status, names/doses/admin schedule of concurrent agents.
Prescriber attestation and signature with date; plan or designees may audit and request medical information to verify accuracy.

What providers must do

Documentation Required

Complete required form fields

Complete all asterisked (*) items on the form so Cigna can respond via fax. Include all required clinical details: diagnosis (ICD-10), prior therapies, medication dose/frequency/duration/start date, patient weight, and urgency selection. Provide prescriber attestation and signature with date.

Prior Authorization

Submit prior authorization request

Fax the completed form to (855) 840-1678. You may also submit online via CoverMyMeds or via SureScripts in your EHR. For urgent requests call (800) 882-4462 to expedite review.

Billing Rule

Site-of-care consideration

Indicate the facility and/or doctor dispensing and administering the medication, including facility name, tax ID and address. Answer site-of-care questions and state whether the infusion can be redirected to a lower-cost medically appropriate setting; note that some Cigna plans require infusion in the lowest-cost medically appropriate setting.

Documentation Required

Medication sourcing

Specify where the medication will be obtained. Cigna's nationally preferred specialty pharmacy is Accredo; if using Accredo provide ordering details (e-prescribe, Accredo address, NCPDP 4436920, Fax 888.302.1028, Verbal 866.759.1557). If medication will be obtained elsewhere (prescriber office stock, retail, home infusion, other) indicate that selection and provide ordering details as applicable.

Form purpose & administrative details

Authorization form for Kadcyla (trastuzumab emtansine) used to gather clinical and administrative information necessary for Cigna to perform utilization review and coverage determination. The form includes site-of-care questions about infusion setting, candidacy for re-direction to alternate settings, home infusion, and whether infusion must occur in the lowest cost medically appropriate setting.

Medication sourcing options are captured, including Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy), prescriber's office stock billed on a medical claim, retail pharmacy, home health/home infusion vendor, or other vendor.

Disease-specific clinical checkboxes capture diagnosis categories for early breast cancer (EBC), breast cancer, non-small cell lung cancer (NSCLC), and salivary gland tumors of the head and neck, with follow-up items such as HER2-positive status, adjuvant use and residual invasive disease after neoadjuvant therapy for EBC, prior taxane/Herceptin therapy, recurrent or metastatic disease, single-agent use, prior trastuzumab or taxane exposure, and presence of HER2 mutations for NSCLC.

The form also collects patient and prescriber identifiers, urgency designation (Standard or Urgent with attestation), the requested dose/frequency/duration/start date, ICD-10 diagnosis, additional pertinent clinical details (disease stage, prior therapy, performance status, concurrent agents), and requires prescriber attestation and signature.

OpenPayer

prior_authorization_request_form_kadcyla

Policy overview

Form completion & clinical questions

Diagnosis codes

What providers must do

Form purpose & administrative details

Revision history