CurrentCignaPolicy N/A

Ketalar (ketamine) prior authorization and coverage request form

This is a Cigna prior authorization and coverage request form for Ketalar (ketamine) used across indicated diagnoses; it governs submission requirements for providers requesting coverage and affects patients and prescribing clinicians seeking drug authorization.

Policy Summary

PayerCigna

PolicyKetalar (ketamine) prior authorization and coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Ketalar request form with medication name, dose, quantity, ICD-10 diagnosis, clinical justification and prescriber signature via fax to (855) 840-1678 or online at CoverMyMeds.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

855-840-1678fax for completed form

800-882-4462phone for urgent requests

Accredopreferred specialty pharmacy

Coverage & Submission Criteria

Administrative submission criteria

Covered when ALL of the following administrative submission elements are provided

Submission requirements: Completed asterisked patient/provider identifiers; medication name (Ketalar), directions/dose, quantity; ICD-10 diagnosis; clinical information supporting indication; prescriber signature and date; facility/dispensing information if applicable.

These are administrative prerequisites for review, not clinical-criteria determinations.

The form does not list any explicit clinical exclusion conditions. It focuses on collecting required patient and provider identifiers and clinical information rather than enumerating diagnoses or situations that would be excluded from consideration.

There are no statements on the form declaring any requests as not medically necessary. The document solicits the diagnosis related to use (e.g., Bipolar Disorder, Chronic Pain, Complex Regional Pain Syndrome, Major Depressive Disorder) and clinical information to support authorization, without providing a list of conditions considered not medically necessary.

Coding & Response Time

Requested diagnosis code fieldICD-10

ICD10

ICD-10 diagnosis code must be provided (form field labeled ICD10)

Policy Summary

PayerCigna

PolicyKetalar (ketamine) prior authorization and coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Specialty pharmacy identifierNCPDP

NCPDP 4436920

Accredo pharmacy identifier

Response time — standard response time for prescription drug coverage requests

Standard response timeOur standard response time for prescription drug coverage requests is 5 business days.

Urgent requestsIf the request is urgent, call the phone number provided to expedite the request.

Online submission optionSave time by submitting online at CoverMyMeds or via SureScripts in your EHR.

Provider Requirements & Submission Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required via submission of the Ketalar (ketamine) request form. Complete and submit the form with the requested medication, dose, quantity, and ICD-10 diagnosis to initiate review.

Submit using the Ketalar (ketamine) request form with medication name, dose, quantity, and ICD-10 diagnosis.
Standard response time: 5 business days; call to expedite urgent requests.
Online submission options: CoverMyMeds or SureScripts via EHR.

Note

Form Asks About Chronic/Long-Term Use and Indication

The form asks whether the medication is being requested for a chronic/long-term condition and captures the clinical indication/diagnosis related to use (e.g., Major Depressive Disorder, Bipolar Disorder, Chronic Pain, Complex Regional Pain Syndrome, other).

Form includes checkboxes for listed diagnoses and an 'other (please specify)' field.
Form asks whether medication is for a chronic/long-term condition (provider must indicate).

Documentation Required

Required Documentation

Provider must complete required patient and provider identifiers (all asterisked fields) and provide clinical information to support the request, including diagnosis, directions for use, dose, quantity, and any pertinent clinical history.

Required patient/provider fields (asterisked): Physician name, DEA/NPI/TIN, Patient name, Cigna ID, Date of birth, Patient street address.
Clinical fields required: Medication requested, directions for use, dose, quantity, ICD-10, diagnosis related to use, and 'Clinical Information' free-text.
Additional pertinent information: current use of requested drug (with dates), how therapy has been received (samples, out of pocket), and prescriber attestation/signature.

Denial Risk

Incomplete Form Risk

Incomplete completion of asterisked (*) patient and provider fields will prevent a fax response and may impede processing of the request; ensure all required fields are filled to avoid denial or delay.

If asterisked fields are incomplete, the plan will not respond via fax and processing may be delayed or denied.
Complete prescriber signature and date, and provide contact/fax numbers to facilitate communication.

Clinical & Drug Background

Ketalar (ketamine) is requested on the form for several indications including Bipolar Disorder, Major Depressive Disorder, Chronic Pain, and Complex Regional Pain Syndrome. The form requires clinical information to support the request and completion of asterisked patient and provider identifiers to allow processing and response.

Definitions & Drug Identifier

Ketalar (ketamine) — The requested medication identified on the form; clinical details (dose, directions, quantity) and diagnosis (ICD-10) must be provided for...

Medication identifiedKetalar (ketamine) — medication requested must be indicated on the form.

Clinical details requiredDirections for use, dose, and quantity must be provided on the form.

Diagnosis codeICD-10 diagnosis code must be provided (form field labeled ICD10).

Additional clinical informationProvide pertinent clinical information including current use (with dates) and how drug has been received (samples, out of pocket, etc.).

Prescriber attestationPrescriber signature and date required; attestation that information is true and accurate.

Initial Authorization Requirements

Initial therapy submission

Initial authorization submission requirements

Initial submission fields: Medication name, dose, directions, quantity, ICD-10, clinical rationale, whether medication is for chronic/long-term condition, dispensing site, and prescriber signature.

Submit via fax to (855) 840-1678 or online at CoverMyMeds; urgent cases should be called to expedite.

Step Therapy & Chronic Use

Question	Form content / guidance
Is the medication for a chronic or long-term condition?	The form includes a checkbox question asking whether the medication is for a chronic or long-term condition but provides no additional definition, step-therapy sequence, or prior medication failure requirements on the form itself.

Site of Care & Dispensing

Note

Specify dispensing/infusion site and provide facility details

Indicate where the medication will be obtained on the form (options include Accredo Specialty Pharmacy, hospital outpatient, prescriber's office stock, retail pharmacy, home health/home infusion vendor, or Other) and provide facility/dispensing details when applicable.

Accredo Specialty Pharmacy (Cigna’s nationally preferred specialty pharmacy; NCPDP 4436920)
Hospital outpatient
Prescriber’s office stock (billing on a medical claim form) — provide facility name and Tax ID
Retail pharmacy
Home Health / Home Infusion vendor
Other (please specify)