CurrentCignaPolicy N/A

prior_authorization_form

This is a payer prior authorization request form for the medication Opdualag (nivolumab + relatlimab) 240mg-80mg/20ml solution for infusion to be completed by prescribers to request coverage, capture patient/clinical details, and supply supporting documentation.

Policy Summary

PayerCigna

Policyprior_authorization_form

Policy CodePolicy N/A

Change TypeInformational (form)

Effective Date

Next Review Date

Key ActionProvider must complete all required asterisked fields on the form, attach supporting documentation (genetic testing, chart notes, labs), sign attestation, and submit via provided channels (fax, CoverMyMeds online, SureScripts).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form-based prior authorization requirements remain informational and unchanged.

1Medication Supported by Form

5Standard response time (business days)

Policy snapshot & purpose

This is a Cigna prior authorization request form specifically for Opdualag (nivolumab + relatlimab) 240mg-80mg/20ml solution for infusion. The form is used by prescribers to request coverage and capture required patient and clinical details to allow the insurer to review and authorize therapy.

The form collects key identifiers and contact information for the patient (Cigna ID, name, date of birth, address, phone) and the prescriber (physician name, specialty, DEA, NPI or TIN, office contact, phone, fax, and office address), as well as medication specifics (directions, quantity, duration, J-code, patient weight), diagnosis/ICD-10, site of acquisition, facility dispensing/administration details, and supporting clinical documentation.

Form completion / documentation requirements

Prior authorization will be considered when the following information and supporting documentation are provided:

ALL of the following

Patient identifiers: Cigna ID, patient name, date of birth, patient address, patient phone
Refer to form required asterisked fields
Prescriber identifiers: Physician name, specialty, DEA, NPI or TIN, office address, office contact, phone, fax
Complete all asterisked prescriber fields
Medication requested: selection of Opdualag 240mg-80mg/20ml solution for infusion, directions for use, quantity, duration of therapy, J-code, patient's current weight
Use medication/J-code fields on form
Diagnosis: selection of Melanoma or other (specify) and ICD-10 code
Specify ICD-10 code as provided on the form
Site of acquisition: indicate Accredo Specialty Pharmacy, prescriber's office stock, retail pharmacy, home health/home infusion vendor, or other
Accredo is Cigna's nationally preferred specialty pharmacy; contact/NCPDP provided on form
Facility dispensing/administration details: facility name, state, tax ID, address; indicate if prescriber has an in-office infusion site
Include facility tax ID and address; indicate yes/no for in-office infusion
Clinical information: whether disease is unresectable or metastatic; additional pertinent information including disease stage, prior therapy, performance status, and concurrent agents (names/doses/admin schedule)
This drug requires supportive documentation; attach chart notes, labs, genetic testing as applicable
Supportive documentation attachment: genetic testing, chart notes, lab/test results, and other supporting documentation as required
Supportive documentation for all answers must be attached with this request
Attestation: prescriber signature and date attesting to accuracy and acknowledging potential audit
Prescriber must sign and date; Health Plan or designees may perform routine audit

refChangeNote__ref_not_used__DO_NOT_RELY_ON_THIS_FIELD_FOR_CITATIONS__use_citations_array_instead__ref_b1_0_only__echo_ref_exactly_below__ref_b1_0_DO_NOT_TRUST_THIS_FIELD_OR_REMOVE_IT_LATER___ref_b1_0__do_not_change_this_line___ref_b1_0__echo_ref_exactly_as_requested_in_instruction__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0

ref___DO_NOT_USE___echo_ref_b1_0__THIS_FIELD_IS_REDUNDANT__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0__ref_b1_0

titleChangeNote__do_not_use__echo_title_from_tree_here___Form completion / documentation requirements

ref_b1_0_filler_echo_ref_field___DO_NOT_USE__ref_b1_0

ref_b1_0

Urgency, response time & submission instructions

Urgency and response time

Submission urgency options and standard response time

ALL of the following

Urgency indication: Provider must indicate urgency as Standard or Urgent (urgent attestation required if checked)
Urgent selection requires prescriber attestation that standard review time may seriously jeopardize life/health/function
Response time and escalation: Standard response time for prescription drug coverage requests is 5 business days; providers should call to expedite urgent requests
If request is urgent, call to expedite; standard response time = 5 business days

refChangeNote__ref_not_used__DO_NOT_RELY_ON_THIS_FIELD_FOR_CITATIONS__use_citations_array_instead__ref_b2_0_only__echo_ref_exactly_below__ref_b2_0_DO_NOT_TRUST_THIS_FIELD_OR_REMOVE_IT_LATER___ref_b2_0__do_not_change_this_line___ref_b2_0__echo_ref_exactly_as_requested_in_instruction__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0__ref_b2_0

ref_b2_0

titleChangeNote__do_not_use__echo_title_from_tree_here___Urgency and response time

Prior Authorization

Complete prior authorization form for Opdualag

Provider must complete all required asterisked fields on the form, sign the attestation, attach supporting documentation, and submit the completed form via the provided channels (fax, CoverMyMeds online, or SureScripts).

Documentation Required

Supportive clinical documentation required

Attach supportive documentation for all answers, including genetic testing, chart notes, and lab/test results to substantiate the clinical indication and prior therapies.

Billing Rule

Select medication acquisition and billing source

Indicate where the medication will be obtained by selecting one: Accredo Specialty Pharmacy, prescriber's office stock to be billed on a medical claim, retail pharmacy, home health/home infusion vendor, or other (specify).

Denial Risk

Incomplete forms risk denial

Failure to complete all required asterisked items or to provide the required supporting documentation may prevent the plan from responding via fax and could result in delays or denial of the request.

OpenPayer

prior_authorization_form

Policy snapshot & purpose

Form completion / documentation requirements

Urgency, response time & submission instructions

Code fields on the form

Definitions

Document changes & timeline