Paclitaxel prior authorization form coverage criteria
This document is a Cigna prior authorization and clinical information form for requests to obtain paclitaxel (an infused chemotherapy agent) and governs submission requirements for prescribers and sites requesting coverage. It affects providers submitting prior authorization for paclitaxel and the patients for whom paclitaxel is requested.
No material clinical or coverage changes in this revision.
Coverage Criteria and Form Questions
Form submission and diagnosis-specific clinical questions
Coverage consideration will be based on diagnosis selection and completion of clinical questions relevant to that diagnosis (examples below).
See chunks 1,2,7
See chunk 7
The prior authorization form lists a range of eligible diagnoses for paclitaxel and does not specify any explicit exclusions. The diagnosis section includes many tumor types (for example: breast cancer, ovarian/fallopian tube/primary peritoneal cancer, non‑small cell lung cancer, small cell lung cancer, angiosarcoma, Kaposi sarcoma, anal carcinoma, and multiple other solid tumors) and also provides an Other (please specify) option to capture indications not enumerated on the form. No explicit exclusion conditions are stated on the form itself.
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