CurrentCignaPolicy V010124

Panitumumab (Vectibix) prior authorization form

This document is a Cigna prior authorization form governing requests for coverage of panitumumab (Vectibix) for insured members; it is used by providers to submit clinical and administrative information needed for drug coverage decisions.

Policy Summary

PayerCigna

PolicyPanitumumab (Vectibix) prior authorization form

Policy CodePolicy V010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form (fax or online) or call the urgent number for expedited review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

800.882.4462urgent phone

(855) 840-1678fax

Accredopreferred specialty pharmacy

Coverage Determination Criteria

Information required for coverage review

Coverage determination is based on provider‑submitted clinical information including diagnosis, disease stage, and RAS mutation status.

Policy Summary

PayerCigna

PolicyPanitumumab (Vectibix) prior authorization form

Policy CodePolicy V010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form (fax or online) or call the urgent number for expedited review.

SourceLink

On This Page

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Information required for coverage review: Provider must submit: medication request details (drug name, new start status, start date, dose, frequency, duration), concurrent therapy status, patient weight, ICD‑10 diagnosis code, patient identifiers, and provider identifiers.

Form fields collect these items to support review; completed fields are required for assessment of medical necessity.

Clinical disease status: Provider must indicate whether the patient has advanced or metastatic disease (Yes/No).

This information is requested on the form to support clinical appropriateness for panitumumab.

Tumor RAS mutation status: Provider must document whether the patient's tumor is KRAS or NRAS wild‑type (Yes/No).

Panitumumab efficacy depends on RAS wild‑type status; the form requests KRAS/NRAS status for coverage review.

Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for panitumumab (Vectibix). Submit the completed form by fax or online at CoverMyMeds, or call for urgent review to expedite the request. Our standard response time for prescription drug coverage requests is 5 business days; if urgent, call to request an expedited review.

Submit online: www.covermymeds.com/main/prior-authorization-forms/cigna/
If urgent, call Cigna to request an expedited review

Denial Risk

Incomplete Form Risk

Incomplete or missing asterisked patient and provider identification fields (for example: Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient and Office Street Address) may prevent Cigna from responding via fax and can delay or impede the prior authorization review and determination.

All items marked with an asterisk (*) must be completed to allow fax response and timely processing.

Documentation Required

Required Clinical & Demographic Information

Providers must supply complete patient and provider identifiers and relevant clinical information on the form to support review. Required demographic and administrative fields include physician name, specialty, DEA/NPI/TIN, office contact, office phone and fax, patient name, Cigna ID, date of birth, patient and office street addresses, city, state, zip, and patient phone. Required clinical information includes medication requested (Vectibix/panitumumab), whether this is a new start, start date, dose, frequency and duration of therapy, current weight, ICD-10 diagnosis code, whether medication will be given concurrently with other agents (and details if yes), whether the disease is advanced/metastatic, and KRAS/NRAS wild-type status.

Patient and provider identifiers: Physician Name; Specialty; DEA, NPI or TIN; Office Contact; Office Phone; Office Fax; Patient Name; Cigna ID; Date of Birth; Patient and Office Street Address, City, State, Zip; Patient Phone.
Clinical fields: Medication Requested (Vectibix); New start (yes/no); Start date; Dose; Frequency; Duration; Concurrent agents (specify if yes); Current weight; ICD-10 diagnosis; Advanced/metastatic disease (yes/no); KRAS/NRAS wild-type disease (yes/no).
Attestation and prescriber signature/date required.

OpenPayer

Panitumumab (Vectibix) prior authorization form

Coverage Determination Criteria

Drug Coding and Response Time

Provider Submission Requirements & Actions

Dispensing and Administration Site Options

Key Clinical Definitions

Clinical Background