CurrentCignaPolicy N/A

Patient information and prior authorization form for Axtle (pemetrexed) infusions

This document is a patient/physician fillable prior authorization form used to request coverage for Axtle (pemetrexed) infusions through Cigna; it governs information collection and submission pathways for providers and affects prescribers seeking drug coverage for insured Cigna members.

Policy Summary

PayerCigna

PolicyPatient information and prior authorization form for Axtle (pemetrexed) infusions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed patient information prior authorization form, including medication selection, dosing, ICD-10 diagnosis, clinical details, and facility/pharmacy source; call for urgent requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

855-840-1678fax to submit

800-882-4462urgent phone

Accredopreferred specialty pharmacy

Coverage Criteria

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The form frames coverage-related clinical information by requesting diagnosis-specific details and treatment context for use of Axtle (pemetrexed). For each listed malignancy the form collects disease status (for example, locally advanced, metastatic, recurrent), prior-therapy history, and whether the medication will be used as single-agent or in combination with pembrolizumab/Keytruda. For non–small cell lung cancer the form also asks about histology (squamous vs non-squamous) and prior systemic therapy. The questionnaire includes branching items tied to prior chemotherapy (including platinum exposure) and maintenance intent so reviewers can assess whether submitted clinical circumstances match expected indications and sequencing.

The form is a data-collection tool used to determine medical necessity rather than a standalone coverage policy. It asks providers to supply identifying information, diagnosis and treatment details, and an attestation that the clinical information is accurate; those responses are used by Cigna or its designees to review and render a coverage decision. The form does not itself state explicit approval or denial language; instead it requests the clinical elements reviewers need to evaluate whether the requested infusion meets plan criteria.

Requested Drug and Diagnosis Coding

Requested drug and diagnosis fieldsmixed

Axtle 100mg vial	Medication requested option listed
Axtle 500mg vial	Medication requested option listed
ICD10	Field for diagnosis code

Platinum-based chemotherapy exposure — key clinical detail captured

ThresholdPlatinum-based (carboplatin or cisplatin) chemotherapy given as part of first-line treatment with at least 4 cycles

Verification question on formForm asks: 'Did your patient receive at least 4 cycles of the platinum-based chemotherapy?' with Yes/No options

Follow-up assessmentIf at least 4 cycles were given, form asks whether disease progression occurred after 4 cycles

Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission Requirements

Prior Authorization Required: Prior authorization requests must include a completed patient information form with all required fields, selection of the requested Axtle strength (Axtle 100mg vial or Axtle 500mg vial), detailed clinical information (diagnosis, disease stage, prior therapies, performance status, concurrent agents and dosing, intended dose/frequency/duration, start date), and the prescriber attestation and signature. Submit clinical notes and supporting medical records as needed to substantiate the request. Standard response time is 5 business days; call if the request is urgent to expedite review.

Medication selection must specify Axtle strength: Axtle 100mg vial or Axtle 500mg vial.
Include dose, frequency, duration, start date, and ICD-10 diagnosis code.
Provide detailed clinical information: diagnosis-related checkboxes, disease stage, prior therapies, whether disease progressed on prior therapy, intended single-agent or combination use, performance status, and any pertinent lab or cytology results when applicable.
Attach prior treatment records and documentation of platinum-based chemotherapy (if applicable) including number of cycles and response/progression when required.
Prescriber attestation and signature are required.

Note

Dispensing / Site Options

Dispensing / Site Options: Accredo Specialty Pharmacy is Cigna’s nationally preferred specialty pharmacy and is the recommended dispensing site. Providers may alternatively obtain medication through hospital outpatient infusion, prescriber office stock (billing on a medical claim), retail pharmacy, home health/home infusion vendors, or other specified sites. When selecting Accredo, orders may be placed via e-prescribe, fax (888.302.1028), or verbal order (866.759.1557). Include the chosen dispensing/site on the submission form.

Preferred: Accredo Specialty Pharmacy (NCPDP 4436920) — orders via E-prescribe, Fax 888.302.1028, or Verbal 866.759.1557.
Alternatives: Hospital Outpatient, Prescriber’s office stock (medical claim), Retail pharmacy, Home Health / Home Infusion vendor, or Other (specify).

Documentation Required

Required Form Fields and Attestation

Required Form Fields & Attestation: All asterisked items on the form are mandatory. Required patient and provider fields include: patient name, Cigna ID, date of birth, patient street address, prescriber name, specialty, and DEA, NPI or TIN. The form must also include medication selection (Axtle strength), dose/frequency/duration, diagnosis (ICD-10), and the prescriber’s attestation and signature. The Health Plan or its designees may request additional medical records to verify the information provided.

Mandatory patient fields: *Patient Name, *Cigna ID, *Date of Birth, *Patient Street Address, Patient Phone.
Mandatory provider fields: *Physician Name, Specialty, *DEA, NPI or TIN, Office Contact, Office Phone, Office Fax, Office Street Address.
Clinical fields required: Medication requested (Axtle strength), Dose, Frequency, Duration, Start Date, ICD-10 diagnosis, and clinical checklist items relevant to the diagnosis.
Attestation: Prescriber must sign and date the attestation statement confirming the accuracy of the information; include contact information for audit requests.

Denial Risk

Incomplete Required Fields

Incomplete Required Fields — Action Required: Due to privacy and processing rules, Cigna will not be able to respond via fax with the outcome of the review unless all asterisked (*) items on the form are completed. Failure to complete required fields may delay processing or result in an inability to adjudicate the request until missing information is received. To avoid delays, complete all mandatory fields and attach supporting medical records when indicated.

If any asterisked items are missing, Cigna may be unable to return a faxed determination.
Incomplete submissions may result in a processing delay or a request for additional information.
For faster processing, submit online at CoverMyMeds or via SureScripts in your EHR when available.

Site of Care

Note

Infusion/site of care: Accredo preferred; include facility/dispensing details for other sites

Provide where the medication will be obtained and how it will be administered: Accredo (preferred) is available for e-prescribe, fax or verbal order; alternatively, medication can be dispensed at hospital outpatient, prescriber office stock (billed on medical claim), retail pharmacy, home health/home infusion, or other facility—include facility name, tax ID, address and indicate if chronic/long‑term use.

Accredo ordering options: e-prescribe, Fax 888.302.1028, or Verbal 866.759.1557 (Accredo address and NCPDP 4436920 listed)
If prescriber office stock will be used, indicate billing on a medical claim and provide facility name, state, Tax ID#, and address
Indicate if medication is for a chronic/long‑term condition

Definitions

Good risk status — definition and qualifiers

DefinitionGood risk status is defined as Karnofsky Performance Scale (KPS) of at least 60, no major neurologic deficits, minimal systemic disease, and reasonable systemic treatment options if needed

Context of useApplied when medication is used as primary treatment for leptomeningeal metastases from NSCLC (form asks: 'Does your patient have good risk status?')

Assessment requirementProvider must indicate Yes or No on the form to document good risk status

Single-agent therapy — definition

DefinitionSingle-agent therapy means no other chemotherapy drugs will be used with this medication

Form promptForm asks whether the medication will be used as 'single agent' or in combination (e.g., with Keytruda only) when prior chemotherapy has been given

Applicability noteFor many diagnoses (except mesothelioma, NSCLC, leptomeningeal metastases from NSCLC, non-nasopharyngeal head and neck cancer) the form specifically asks if medication is being given as single-agent therapy

Background

Pemetrexed (Axtle) is an antineoplastic cytotoxic agent used in the malignancies listed on the form, including non–small cell lung cancer and mesothelioma, as well as ovarian, fallopian tube, primary peritoneal, bladder, cervical and other specified cancers. The form prompts submission of disease stage, prior therapies (including platinum-based chemotherapy), performance status and the names/doses/schedules of concurrent agents to support review of treatment intent (for example, maintenance therapy or single-agent use) and to verify that the requested use aligns with appropriate clinical sequencing.