CurrentCignaPolicy N/A

Prior Authorization Request Form for Selarsdi/Imuldosa/Yesintek IV (ustekinumab products)

This document is a Cigna prior authorization request form to be completed by prescribers for infusion/medical benefit administration or pharmacy dispensing of Selarsdi, Imuldosa, or Yesintek 130mg/26mL (ustekinumab IV) products. It collects patient, prescriber, medication, indication, administration site, and clinical information to support coverage review.

Policy Summary

PayerCigna

PolicyPrior Authorization Request Form for Selarsdi/Imuldosa/Yesintek IV (ustekinumab products)

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 submit online via CoverMyMeds or SureScripts; call (800) 882-4462 for urgent requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is an administrative prior authorization form used to collect information for coverage review.

3Product options listed on form

6Sample indications listed

1Specialty pharmacy named

Policy overview

This is a Cigna prior authorization request form to be completed by prescribers for infusion/medical benefit administration or pharmacy dispensing of Selarsdi, Imuldosa, or Yesintek 130mg/26mL (ustekinumab IV). The form collects administrative and clinical data to support coverage review, including patient and prescriber identification (required asterisked fields such as patient name, Cigna ID, date of birth, physician name, DEA/NPI/TIN), medication requested and dosing details (product selection, dose/quantity, frequency, duration, J‑code, ICD‑10, patient weight), the indication/diagnosis (e.g., ankylosing spondylitis, Crohn’s disease, plaque psoriasis, psoriatic arthritis, ulcerative colitis, other), and clinical information (use with other biologic or targeted synthetic agents and disease‑specific items such as induction therapy and gastroenterology prescriber status for Crohn’s/ulcerative colitis).

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What providers must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. For urgent/expedited requests call (800) 882-4462.

Documentation Required

Complete all starred fields for response

Providers must complete all asterisked (*) items on the form (patient identifiers and prescriber identifiers such as DEA, NPI, or TIN) for Cigna to be able to respond via fax.

Documentation Required

Clinical information and indication selection required

Indicate the requested medication, dose/quantity, frequency of administration, and duration; specify the indication (e.g., ankylosing spondylitis, Crohn's disease, plaque psoriasis, psoriatic arthritis, ulcerative colitis, or other), whether therapy is induction or chronic, and whether the medication will be used in combination with another biologic or targeted synthetic agent.

Documentation Required

Specialty pharmacy / acquisition site selection

Document where the medication will be obtained (options include Accredo Specialty Pharmacy, hospital outpatient, retail pharmacy, home infusion/home health vendor, or physician's office stock) and provide facility/dispensing details such as facility name, address, state, and Tax ID if applicable.

Documentation Required

Gastroenterology prescriber requirement (when applicable)

For Crohn's disease or ulcerative colitis, indicate whether the medication will be used as induction therapy and whether it is prescribed by or in consultation with a gastroenterologist.

Billing Rule

Accredo specialty pharmacy ordering information

Accredo is Cigna's nationally preferred specialty pharmacy. Medication orders can be placed with Accredo via e-prescribe (NCPDP 4436920), fax 888-302-1028, or verbal 866-759-1557.

Denial Risk

Incomplete form may delay or prevent response

Failure to complete required fields on the form—especially the asterisked items (patient identifiers and prescriber DEA/NPI/TIN)—may prevent Cigna from responding via fax or delay the authorization review.

Background and form purpose

Background: This prior authorization form is used to collect necessary administrative and clinical information to support coverage decisions for intravenous ustekinumab products (Selarsdi, Imuldosa, Yesintek).

Form fields include patient and prescriber identification with required asterisked items (physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, addresses, and contact information) and an urgency indicator for standard versus urgent requests.

Clinical and medication fields capture the medication requested and dosing details (product selection among Selarsdi, Imuldosa, Yesintek 130mg/26mL; dose, quantity, duration, J‑code, frequency, ICD‑10, and patient weight) and the indication/diagnosis (Ankylosing Spondylitis, Crohn’s Disease, Plaque Psoriasis, Psoriatic arthritis, Ulcerative colitis, or other).

The form requires documentation of concomitant therapies (whether the medication will be used with another biologic, a targeted synthetic oral small molecule drug, or a conventional synthetic DMARD) and disease‑specific clinical items (for Crohn’s disease and ulcerative colitis: induction therapy status and whether prescribed by or in consultation with a gastroenterologist).

Administrative/coordination fields request where the medication will be obtained (Accredo Specialty Pharmacy — Cigna’s nationally preferred specialty pharmacy — hospital outpatient, retail, home infusion, physician office stock, or other) and include ordering instructions for Accredo and facility/doctor dispensing and administering medication details (facility name, state, Tax ID, address).

Submission instructions and contact information for prior authorization processing are included (fax completed form to the provided fax number and call the urgent request phone line).

Form statistics

Product options listed on form3

Sample indications listed6

Specialty pharmacy named (Accredo)1

OpenPayer

Prior Authorization Request Form for Selarsdi/Imuldosa/Yesintek IV (ustekinumab products)

Policy overview

What providers must do

Form coding fields

Background and form purpose

Revision history