CurrentCignaPolicy v010124

Portrazza (necitumumab) prior authorization form coverage criteria

This document governs prior authorization and information collection for coverage of Portrazza (necitumumab) for Cigna members, used by providers submitting requests for this specialty oncology medication.

Policy Summary

PayerCigna

PolicyPortrazza (necitumumab) prior authorization form coverage criteria

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form including all asterisked patient and provider identifiers, diagnosis details, prior therapies (names, strengths, dates, durations, and outcomes), planned combination therapy, dosing, start date, and site of administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

800-882-4462urgent phone

Accredopreferred specialty pharmacy

Portrazza 800mgmedication on form

v010124form id

Coverage Criteria

Policy Summary

PayerCigna

PolicyPortrazza (necitumumab) prior authorization form coverage criteria

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Authorization data requirements

Coverage determination is based on completion of the prior authorization form and submission of the required clinical and administrative information.

Form completion and clinical info: All required patient and provider identifiers (asterisked fields) and clinical information must be provided, including diagnosis (NSCLC or other), whether squamous cell and metastatic disease, prior therapies with drug names/strengths/dates/durations and documented results, planned combination with gemcitabine and cisplatin, medication requested (Portrazza 800mg), dosing/duration, start date, site of administration, and prescriber attestation and signature.

Incomplete or missing required fields may prevent review or lead to denial; supports medical necessity review.

The prior authorization form does not list any explicit clinical exclusions for Portrazza. The form instead collects site-of-care choices (including Accredo Specialty Pharmacy, prescriber office stock, retail pharmacy, or home infusion) and other administrative details without enumerating disqualifying clinical conditions.

The form does not specify particular not medically necessary conditions. Coverage determination is dependent on submission of the completed prior authorization form and the clinical information requested; absence of required clinical details (diagnosis, prior therapies and documented results, planned combination therapy, disease stage, performance status, dosing and administration plan) may preclude approval or prevent review.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Portrazza. Complete and submit the prior authorization form (all required fields marked with an asterisk) — incomplete forms may result in denial or delay of the request.

Prior authorization required for Portrazza (necitumumab).
Complete all asterisked physician and patient identifiers (e.g., Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Address).

Documentation Required

Required Clinical and Administrative Documentation

The completed form must include clinical details to support medical necessity. Provide diagnosis (confirm squamous cell NSCLC and metastatic status where applicable), ICD-10 code, prior therapy history (drug names, strengths, dates, duration, and documented results), disease stage, performance status, and planned regimen (including whether Portrazza will be given with gemcitabine and cisplatin).

Diagnosis details: squamous cell NSCLC indicator, metastatic disease indicator, ICD-10 code.
Prior therapies: list drug name, strength, dates taken, duration, and response/documented results.
Treatment plan: strength, dose, directions for use, start date, duration, and concurrent agents (e.g., gemcitabine + cisplatin).

Denial Risk

Incomplete Form Risks / Denial Risk

Failure to provide all required patient or physician information or to document prior therapies and relevant clinical details may result in denial or delayed processing. If urgent review is requested, call the plan in addition to submitting the form to expedite.

Missing asterisked identifiers or contact information may prevent faxed notification of the decision.
Omitted prior therapy details (drug names/strengths/dates/results) or absent clinical indicators (stage, performance status) increases risk of denial or delay.
Standard response time is 5 business days; for urgent requests, contact the plan by phone after submission.

Initial Therapy Criteria

Initial therapy information

Initial therapy requests must indicate whether the patient is treatment‑naive or previously treated and must list prior therapies.

Initial request data: Indicate if this is a new start (Yes/No), provide start date, and specify diagnosis details including whether squamous histology and metastatic disease are present.

Form fields capture these items (Is this a new start?, Start Date, Diagnosis checkboxes).

Prior therapy history: If the patient has previously received therapy for this diagnosis, list all alternatives tried with drug name, strength, date(s) taken, duration, and documented results of each therapy.

Required to document prior treatment exposure and outcomes for medical necessity review.

Planned regimen details: Indicate whether Portrazza will be given in combination with gemcitabine and cisplatin and provide names/doses/administration schedule of any agents to be used concurrently, plus disease stage and performance status.

Supports assessment of appropriateness of initial therapy and combination use.

Prior therapy (drug name, strength)	Dates / duration	Documented outcome / reason for discontinuation
Provide each prior systemic therapy tried for this diagnosis (drug name and strength)	Include dates taken and duration for each therapy	Describe documented results for each agent (response, progression, intolerance), or reason for discontinuation

Site of Care and Dispensing

Note

Specify infusion center / site of care and preferred specialty pharmacy

The form collects the intended source and site of administration and lists Accredo as Cigna's nationally preferred specialty pharmacy; it also captures options for prescriber's office stock (medical claim), retail, home infusion, or specific facility/doctor dispensing information.

Where will this medication be obtained? options include Accredo Specialty Pharmacy (nationally preferred), prescriber's office stock (medical claim), retail pharmacy, or home health/home infusion.
Facility and dispensing provider fields capture facility name, tax ID, and address; form asks if patient is candidate for home infusion or if physician has in-office infusion site.

Definitions

NSCLC

Field on formCheckbox for 'non-small cell lung cancer (NSCLC)' to indicate diagnosis related to use

Associated questionForm also asks whether the patient has squamous cell NSCLC (yes/no)

PurposeCaptures the clinical indication for Portrazza to support prior authorization review

Metastatic disease

Field on formCheckbox asking 'Does your patient have metastatic disease? (Yes/No)'

Related staging infoForm requests additional pertinent information including disease stage and prior therapy

PurposeCaptures metastatic status to inform therapy decisions and medical necessity review

Background

Portrazza (necitumumab) is described on the form as an oncology monoclonal antibody intended for use in non-small cell lung cancer (NSCLC). The form captures relevant disease characteristics (whether the tumor is squamous cell and whether disease is metastatic), prior therapy history and specifics, and whether Portrazza will be administered in combination with gemcitabine and cisplatin. The form also collects intended source and site of administration (including Accredo Specialty Pharmacy, noted as Cigna’s nationally preferred specialty pharmacy, prescriber office stock, retail pharmacy, or home infusion), which informs dispensing and billing route for the request.

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