CurrentCignaPolicy v010124

Opdualag (nivolumab + relatlimab) prior authorization form

Prior authorization form for requesting coverage of Opdualag infusion therapy (nivolumab 240 mg + relatlimab 80 mg/20 mL) for Cigna members; used by prescribers and office staff to submit clinical and administrative information needed for review.

Policy Summary

PayerCigna

PolicyOpdualag (nivolumab + relatlimab) prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with medication details, J‑code, patient weight, diagnosis, and attach supportive clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

Opdualagmedication request listed on form

Accredonationally preferred specialty pharmacy

NCapplicable state explicitly listed

Coverage Criteria and Decisioning

Information needed for medical necessity review

Coverage determination is contingent on submission of required clinical information.

Required submission items: Submit supportive documentation (genetic testing, chart notes, lab results), indicate unresectable/metastatic status, provide prior therapy and performance status, and complete all mandatory identifiers.

Form does not enumerate explicit medical necessity clinical thresholds; this information supports review.

The prior authorization form does not list any explicit coverage exclusions for Opdualag. The form is structured to collect clinical and administrative information to inform a coverage decision, but it does not specify defined exclusion criteria on the face of the form.

The form does not enumerate specific conditions that are automatically considered Not Medically Necessary. Instead, determinations about medical necessity are made after review of the submitted clinical documentation (supportive records, disease stage, prior therapies, performance status, etc.).

Billing and Diagnosis Codes

Billing codemixed

J-code

Placeholder field on form for applicable J-code for infusion billing

Policy Summary

PayerCigna

PolicyOpdualag (nivolumab + relatlimab) prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with medication details, J‑code, patient weight, diagnosis, and attach supportive clinical documentation.

SourceLink

On This Page

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Provider Submission Requirements and Warnings

Prior Authorization

Prior authorization submission requirements

Include the following on the prior authorization request: medication name and formulation (Opdualag 240mg-80mg/20ml), directions for use, quantity, duration of therapy, applicable J‑Code, patient’s current weight, and ICD‑10 diagnosis; indicate if disease is unresectable or metastatic.

Medication Requested: Opdualag 240mg-80mg/20ml
Directions for use, Quantity, Duration of therapy
J‑Code
Patient's current weight
ICD10 diagnosis; indicate unresectable or metastatic status

Step Therapy

Source of medication — specify vendor or setting

Specify where the medication will be obtained by selecting Accredo Specialty Pharmacy, prescriber's office stock (billing on a medical claim), retail pharmacy, home health/home infusion vendor, or Other.

Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy)
Prescriber's office stock (medical claim)
Retail pharmacy
Home Health / Home Infusion vendor
Other (please specify)

Documentation Required

Required supportive clinical documentation

Attach required supportive clinical documentation with the request, including genetic testing, chart notes, lab/test results, disease stage, prior therapies, performance status, and names/doses/schedules of concurrent agents.

Genetic testing reports
Chart notes and clinical history
Relevant lab/test results
Disease stage and unresectable/metastatic status
Prior therapy details
Performance status
Names, doses, and administration schedules of concurrent agents

Documentation Required

Mandatory identifying information — complete all asterisked fields

Complete all asterisked patient and provider identifiers on the form; responses will not be returned via fax unless these items are completed.

Physician name and specialty
DEA, NPI, or TIN
Patient name
Cigna ID
Date of birth
Patient street address
Office contact, phone, fax, and office address

Denial Risk

Missing supportive documentation may delay or deny request

Failure to attach the required supportive documentation may prevent completion of the review and can delay or result in denial of the authorization request.

Supportive documentation required (genetic testing, chart notes, labs) must be attached
Incomplete documentation may lead to inability to complete review

Initial Therapy Submission Requirements

Initial therapy submission requirements

Information requested to support initial therapy authorization.

Initial authorization data: Provide medication details (Opdualag 240mg-80mg/20ml), directions, quantity, duration, J-code, patient weight, ICD-10 diagnosis, indicate whether disease is unresectable or metastatic, list diagnosis (Melanoma or other), state prior therapies, performance status, and attach supportive documentation (genetic testing, chart notes, lab/test results).

Form is for initial prior authorization submission; specific clinical eligibility criteria are not listed on the form itself.

Site of care and dispensing information: Indicate facility and/or doctor dispensing and administering medication (facility name, state, tax ID, address), whether the physician has an in‑office infusion site, and where the medication will be obtained (e.g., Accredo specialty pharmacy, prescriber's office stock, retail pharmacy, home infusion, or other).

Include prescriber attestation and signature as provided on the form.

OpenPayer

Opdualag (nivolumab + relatlimab) prior authorization form

Coverage Criteria and Decisioning

Billing and Diagnosis Codes

Provider Submission Requirements and Warnings

Initial Therapy Submission Requirements

Site of Care and Dispensing Options

Clinical Background

Drug and Term Definitions