CurrentCignaPolicy N/A

Injectafer (ferric carboxymaltose) patient information and prior authorization form

Form and instructions used by providers to request coverage/authorization for Injectafer (ferric carboxymaltose) including clinical questions, site-of-care, and dispensing details; affects prescribers and facilities submitting requests to Cigna.

Policy Summary

PayerCigna

PolicyInjectafer (ferric carboxymaltose) patient information and prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request including medication vial size, dose/quantity, duration, frequency, J-code, ICD-10 diagnosis, and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Injectaferdrug named on form

2listed vial options

5 business daysstandard response time

NCapplicable state

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Overall

Indication: Iron deficiency associated with heart failure OR Iron deficiency anemia (with or without CKD) OR cancer/chemotherapy-related anemia
If heart-failure-associated, prescriber should be or consult a cardiologist or hematologist; if CKD on dialysis, note dialysis status; if CKD not on dialysis, prescriber should be or consult nephrologist or hematologist.
Prior therapy and intolerance: If not heart-failure-associated and not CKD on dialysis, patient should have tried oral iron unless intolerance or malabsorption documented; if not a candidate for oral iron, document ineffective or intolerable response; for non-dialysis CKD-related anemia, trial of at least one alternative IV iron (INFeD, Ferrlecit, or Venofer) is required unless exception applies.
Form includes checkbox attestations for these items.
Dosing limits: Requested dosing for iron deficiency anemia (except CKD on dialysis) should not exceed a cumulative total of 1500 mg IV per 30 days.<=1500 mg/30 days
Form asks prescriber to confirm this.

Indication (detail): Will the requested medication be used for iron deficiency associated with heart failure? If yes, is medication being prescribed by (or in consultation with) a cardiologist or hematologist? If no, does the patient have a diagnosis of iron deficiency anemia? If CKD, indicate dialysis status and, if not on dialysis, confirm nephrology or hematology consult and whether prior IV iron (INFeD, Ferrlecit, or Venofer) was tried.

From form branching questions.

Oral iron and absorption: For non–heart-failure and non–CKD-on-dialysis cases: document whether oral iron was tried; if not used, document intolerance or a condition interfering with oral absorption (e.g., inflammatory bowel disease).

Form captures oral iron trial and absorption impairment.

ESA and cancer-related anemia: If iron deficiency anemia not associated with CKD or heart failure, indicate whether the request is for cancer- or chemotherapy-related anemia and whether the patient is receiving an erythropoiesis-stimulating agent.

Form includes ES A status and cancer-related question.

Prior IV iron for non-dialysis CKD: If CKD and not on dialysis, confirm trial of at least one alternative IV iron: INFeD, sodium ferric gluconate complex (Ferrlecit, generics), or Venofer.

Form asks for selection of prior IV iron agents.

Dosing confirmation: Prescriber must confirm requested dosing is a maximum cumulative total of 1500 mg given intravenously per 30 days for iron deficiency anemia (except with CKD on dialysis).<=1500 mg/30 days

Attestation checkbox present on form.

Some Cigna plans require that infusion occur in the least intensive, medically appropriate setting. If a lower-intensity setting (for example, physician office or home infusion) is medically appropriate for the patient, infusion in a higher-intensity setting (for example, hospital outpatient) may be denied or require justification and case management support for redirection. Providers should document the medical rationale if a higher-intensity setting is requested and indicate whether the patient is a candidate for redirection with the assistance of a Specialty Care Options Case Manager.

Prior authorization requests must include complete clinical documentation to support medical necessity. The form captures the indication, prior trials and intolerances (such as prior oral iron therapy or prior IV iron alternatives when applicable), prescriber specialty or consult notes, and whether therapy was previously initiated and requires completion. Requests that lack documentation of the stated indication, prior trials or documented intolerance/malabsorption, or that do not include required billing details (vial size, dose/quantity, frequency, J‑code and ICD‑10 diagnosis) may be considered incomplete or may be denied. Ensure prescriber and facility identifiers, prescriber signature, and NDC/J‑code information are provided as requested on the form.

Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Data Required

Prior authorization required: complete all prior authorization fields on the form. Include specific medication vial size (e.g., Injectafer 100 mg/2 mL or 750 mg/15 mL or other), exact dose and total quantity requested, duration of therapy, frequency of administration, applicable J‑code, and ICD‑10 diagnosis code. Provide NDC when applicable on medical claim per Cigna guidance.

Medication: specify vial size (Injectafer 100 mg/2 mL or 750 mg/15 mL, or other)
Dose and Quantity
Duration of therapy
Frequency of administration
J‑code
ICD‑10
NDC on claim when required

Documentation Required

Form Requires Physician, Practice, Facility, and Patient Identifiers

The prior authorization form must include physician and practice identifiers and complete patient identifiers: prescriber name, specialty, DEA/NPI/TIN, office contact and phone/fax/address; facility/dispensing provider name, Tax ID, and address; and patient name, Cigna ID, date of birth, street address, and phone. Forms lacking these identifiers may delay or prevent review.

Prescriber: Physician Name, Specialty, DEA, NPI or TIN, Office Contact, Phone, Fax, Office Address
Patient: Patient Name, Cigna ID, Date of Birth, Street Address, Phone
Facility/Administrator: Facility Name, Tax ID, Address (City, State, Zip)

Prior Authorization

Prior Therapy Requirement for Iron Deficiency Anemia (non‑dialysis)

For iron deficiency anemia in non‑dialysis patients, prior therapy with at least one alternative IV iron product (INFeD, sodium ferric gluconate complex/Ferrlecit, or Venofer) is required unless an exception is documented. If oral iron was tried but was ineffective or intolerable, indicate that on the form. Also document consultation with or prescription by a nephrologist or hematologist when indicated.

Requirement: trial of ≥1 alternative IV iron (INFeD, Ferrlecit, or Venofer) unless documented exception
If oral iron attempted: indicate whether ineffective or intolerable
If non‑dialysis CKD: note nephrology/hematology prescriber or consultation

Denial Risk

Denial Risk for Non–Least‑Intensive Site of Care

Infusion site selection: per some Cigna plans, infusion may be denied if the medication is administered in a setting that is more intensive than the least intensive medically appropriate site. Indicate intended administration site (home, physician office, hospital outpatient, other) and document medical necessity if a higher‑intensity site is required. Consider re‑direction options with Specialty Care Options Case Manager where appropriate.

Document intended site: Patient Home, Physician Office, Hospital Outpatient, or Other
If higher‑intensity site used, provide medical necessity rationale
Consider re‑direction to alternate site and document discussions with Case Manager

Step Therapy Requirements

Step	Requirement before approval
1	For iron deficiency anemia in patients not on dialysis: patient must have tried at least one alternative IV iron (INFeD, sodium ferric gluconate complex [Ferrlecit, generics], or Venofer) prior to approval unless documentation supports an exception (e.g., intolerance, initiated therapy with Injectafer and needs completion of current course).
2	If not heart‑failure–associated and not CKD on dialysis, trial of oral iron is required unless prescriber documents intolerance or a condition interfering with oral iron absorption.
3	If patient has initiated Injectafer and requires completion of the current course, prescriber may attest to ongoing therapy in lieu of prior alternative trial documentation.

Site of Care and Administration

Note

Document site of acquisition and administration; use least‑intensive appropriate setting

Specify where the medication will be obtained and where it will be administered using the form options (home, physician office, infusion center/hospital outpatient); the form instructs that infusion should occur in the least intensive, medically appropriate setting when required by plan.

Acquisition options captured: Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, Physician's office stock, Other
Administration options captured: Patient's Home, Physician's Office, Hospital Outpatient, Other
Form asks whether patient is a candidate for redirection to an alternate (less intensive) setting with Specialty Care Options Case Manager assistance

Background

Injectafer (ferric carboxymaltose) is an intravenous iron formulation used to treat iron deficiency and iron deficiency anemia, including iron deficiency associated with heart failure and chronic kidney disease. The prior authorization form captures the specific indication (including dialysis status for CKD), whether the prescriber is or consulted a relevant specialist (cardiology, nephrology, or hematology), prior oral iron use or intolerance, prior IV iron trials when required, and whether therapy has already been initiated and requires completion. For dosing control, the form queries whether the requested dosing for non‑dialysis iron deficiency anemia is a maximum cumulative total of 1500 mg IV per 30 days.

Policy Summary

PayerCigna

PolicyInjectafer (ferric carboxymaltose) patient information and prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request including medication vial size, dose/quantity, duration, frequency, J-code, ICD-10 diagnosis, and supporting clinical documentation.

SourceLink

On This Page

OpenPayer

Injectafer (ferric carboxymaltose) patient information and prior authorization form

Coverage Criteria

Coding and Dosing Limits

Provider Submission Requirements & Actions

Initial Therapy Requirements

Continuation / Ongoing Therapy

Step Therapy Requirements

Quantity Limits

Site of Care and Administration

Definitions

Background