CurrentCignaPolicy N/A

Nulibry Prior Authorization Form

A Cigna prior authorization request form to collect required patient, prescriber, and clinical information to support coverage/review of Nulibry (fosdenopterin) for treatment of Molybdenum cofactor deficiency (MoCD) Type A. It documents administrative routing (fax/phone), urgency options, site of care, and required supportive documentation items.

Policy Summary

PayerCigna

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief; document is an administrative prior authorization form collecting required information to support review.

1Indication focused on

RequiredSupportive documentation

Fax/Phone/OnlineSubmission methods

Policy summary & scope

This Cigna prior authorization form collects administrative and clinical information to evaluate requests for Nulibry (fosdenopterin) for treatment of Molybdenum cofactor deficiency (MoCD) Type A, including patient and prescriber identifiers, diagnosis, dose and site of administration. Submit the completed form by fax to (855) 840-1678 or online via CoverMyMeds/SureScripts; for URGENT requests call (800) 882-4462 to expedite. The form emphasizes documentation of genetic confirmation (MOCS1) or, if testing is pending, supportive laboratory findings, and requires that the prescriber be a pediatrician, geneticist, or MoCD specialist (or that consultation with such a specialist is documented).

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Information requested to support prior authorization determination

Form collects required elements used in clinical review; items marked with * are required for response by fax.

Top-level required items

Patient and prescriber identifiers: Patient identifiers and contact: Patient Name, Cigna ID, Date of Birth, Patient Street Address, Patient Phone; Prescriber identifiers and contact: Physician Name, Specialty, DEA/NPI/TIN, Office Contact Person, Office Phone, Office Fax, Office Street Address
Asterisked items required for fax response
Medication request details: Medication requested: Nulibry 9.5mg powder for injection; dose, quantity, frequency, duration; urgency (standard or urgent)
Diagnosis / indication: Diagnosis (ICD-10) and indication: Is medication being used to treat MoCD Type A? If no, specify diagnosis
Genetic testing for MOCS1: Has the patient had genetic testing for variants in the MOCS1 gene? Yes/No
If genetic testing pending
- Genetic testing pending status: Are genetic testing results still pending? Yes/No
- Laboratory findings when pending: If pending: Does the patient have laboratory findings suggestive of MoCD? (e.g., elevated urinary S-sulfocysteine, thiosulfate, xanthine, hypoxanthine, or decreased serum uric acid) Yes/No
If genetic testing completed: Has testing confirmed biallelic pathogenic or likely pathogenic variants in MOCS1 gene? Yes/No
Expected benefit / disease stage: Documentation that patient is expected to derive benefit and disease is not too advanced? Yes/No
Include disease stage, prior therapy, performance status
Specialist involvement: Is prescriber a pediatrician, geneticist, or physician who specializes in MoCD Type A, or is there consultation with such a specialist? Yes/No
Supportive documentation to attach: Attach supportive documentation: genetic test results, chart notes, lab/test results, prior therapies, performance status, dosing and concurrent agents
Supportive documentation required with request
Site of procurement: Biologics, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion, Physician's office stock, Other
Site of administration: Patient's Home, Physician's Office, Hospital Outpatient, Other; note that per some Cigna plans infusion must occur in the least intensive, medically appropriate setting and ask about candidate for redirection with Specialty Care Options Case Manager
Attestation and signature: Attestation and prescriber signature/date

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Actions required by provider

Prior Authorization

Submit completed prior authorization form

Fax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests must be called to (800) 882-4462 to expedite.

Fax: (855) 840-1678
Online portals: www.covermymeds.com or via SureScripts in your EHR
Urgent requests: call (800) 882-4462

Documentation Required

Attach supportive documentation

Attach genetic test results, chart notes, laboratory/test results (including laboratory findings suggestive of MoCD when genetic testing is pending), prior therapy and performance status to support the request.

Genetic test results (MOCS1)
Lab/test results (e.g., elevated urinary S‑sulfocysteine, thiosulfate, xanthine, hypoxanthine, or decreased serum uric acid)
Chart notes
Prior therapies
Performance status
Dosing and names/schedules of concurrent agents

Documentation Required

Specialist involvement

Indicate whether the prescriber is a pediatrician, geneticist, or a physician who specializes in MoCD Type A, or provide documentation of consultation if the prescriber is not one of these specialists.

Acceptable specialists: pediatrician, geneticist, or physician who specializes in molybdenum cofactor deficiency (MoCD) Type A
If prescriber is not a specialist, document consultation with one of the above

Billing Rule

Site of administration note

Document intended procurement and the site where the drug will be administered. Note that per some Cigna plans, infusion must occur in the least intensive medically appropriate setting; consideration of redirection to an alternate setting with assistance from a Specialty Care Options Case Manager may be requested.

Document site of procurement (e.g., Biologics, Hospital Outpatient, Retail, Home Health/Home Infusion, Physician's office stock)
Document site of administration (Patient's Home, Physician's Office, Hospital Outpatient, etc.)
Some Cigna plans require the least intensive medically appropriate setting and may involve redirection with a Specialty Care Options Case Manager

Background & definitions

The form's primary purpose is to gather the clinical and administrative details needed for prior authorization review of Nulibry (fosdenopterin) for MoCD Type A, including medication specifics, diagnosis (ICD-10), dosing, duration, and site of procurement/administration. It also requests supporting documentation such as genetic test results, chart notes, lab/test results, prior therapies, and performance status to support medical necessity.

There is an emphasis on genetic confirmation: the form asks whether the patient has undergone genetic testing for variants in the MOCS1 gene and, if testing is complete, whether results confirm biallelic pathogenic or likely pathogenic variants in MOCS1. If genetic testing is still pending, the form requests documentation of laboratory findings suggestive of MoCD (for example, elevated urinary S-sulfocysteine, thiosulfate, xanthine, hypoxanthine, or decreased serum uric acid). The form also requires that the prescriber be a pediatrician, geneticist, or a physician who specializes in MoCD Type A, or that consultation with such a specialist be documented.

Term	Definition
MoCD
Molybdenum cofactor deficiency
MOCS1
Gene associated with MoCD Type A; biallelic pathogenic or likely pathogenic variants are requested if available

OpenPayer

Nulibry Prior Authorization Form

Policy summary & scope

Information requested to support prior authorization determination

Requested product / codes

Actions required by provider

Background & definitions

Submission methods & administrative routing

Document changes