CurrentCignaPolicy N/A

Erbitux_Prior_Authorization_Form

A payer prior authorization/authorization form for requesting coverage of Erbitux (cetuximab) including patient, prescriber, clinical, and dispensing details to support review. It captures diagnosis, biomarkers, prior therapy, treatment intent, site of infusion, and pharmacy/facility sourcing.

Policy Summary

PayerCigna

PolicyErbitux_Prior_Authorization_Form

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 call (800) 882-4462 for urgent requests to expedite review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form collects clinical and administrative details for prior authorization.

1Form version

5dStandard response time

Policy summary

This is a Cigna prior authorization request form for Erbitux (cetuximab) used to collect patient, prescriber, clinical, and dispensing details to support review. The form gathers diagnosis, biomarker status, prior therapies, treatment intent, infusion logistics, and pharmacy/facility sourcing to evaluate coverage.

Form version: 1.

Form sections and requested information

Form Completion / Triage Questions

Information requested to support prior authorization review; not explicit coverage rules but used for medical necessity evaluation.

Patient identifying information: patient name, Cigna ID, date of birth, address, phone

Physician information: physician name, specialty, DEA, NPI or TIN, office contact, phone, fax, address

Urgency selection: Standard or Urgent (if Urgent attest that standard review may seriously jeopardize life/health/ability to regain function)

Medication requested: Erbitux (cetuximab); indicate new start Yes/No, start date, dose, frequency, length of therapy

Treatment logistics: where medication will be obtained (Accredo Specialty Pharmacy, prescriber's office stock, retail pharmacy, home health/home infusion vendor, other)

Facility/dispensing info: facility name, state, tax ID, address

Home infusion candidate and availability of in-office infusion site

Indication selection: colorectal cancer (CRC), head/neck cancer, non-small cell lung cancer (NSCLC), penile cancer, skin cancer, other (specify)

Biomarker and disease-specific questions (KRAS/NRAS wild-type; if CRC advanced/metastatic; EGFR expression; BRAF V600E presence and metastatic disease; combination with encorafenib (Braftovi) if V600E)

Head/neck specific: whether given with radiation as primary treatment; new start vs continuation; if continuation, weeks already received; whether squamous cell carcinoma (head/neck or skin); for skin whether regional recurrence, distant metastases or inoperable positive regional lymph nodes

Penile specific: will be used as single agent therapy; metastatic disease if NSCLC or penile; NSCLC: second-line chemotherapy; NSCLC: combination with afatinib (Gilotrif); NSCLC EGFR-positive disease and prior progression on Gilotrif, Iressa, Tarceva

Additional clinical information: disease stage, prior therapy, performance status, names/doses/admin schedule of concurrent agents

Prescriber attestation and signature with date

Information requested on this form is collected to support prior authorization review and medical necessity evaluation; these items are not explicit coverage rules but provide clinical and administrative details for review.

Requested information includes urgency (Standard or Urgent with attestation), medication start details (new start, start date, dose, frequency, length), biomarker and disease-specific questions (e.g., KRAS/NRAS, EGFR, BRAF V600E), prior therapies and concurrent agents, and additional clinical details.

Administrative items include patient and physician identifying information, facility/dispensing and pharmacy sourcing, home infusion candidacy, and a prescriber attestation and signature.

Submission, documentation, and billing requirements

Prior Authorization

Fax or call to submit authorization

Fax the completed form to (855) 840-1678; urgent requests should be called to (800) 882-4462 to expedite review.

Documentation Required

Complete all required fields

All asterisked (*) items must be completed to receive a response via fax; prescriber must attest and sign the form and provide clinical details including biomarker status, prior therapies, and treatment plan.

Billing Rule

Specify source and billing method for medication

Indicate where medication will be obtained (Accredo Specialty Pharmacy, prescriber's office stock - billing on a medical claim form, retail pharmacy, home health/home infusion vendor, or other).

Prescribers must indicate billing route (medical claim vs pharmacy claim)
Specify chosen pharmacy or home infusion vendor

Documentation Required

Facility/dispensing information required

Provide facility name, state, Tax ID#, and address when medication dispensed/administered by facility or doctor.

OpenPayer

Erbitux_Prior_Authorization_Form

Policy summary

Form sections and requested information

Requested code fields on form

Submission, documentation, and billing requirements

Document changes