CurrentCignaPolicy N/A

Prior authorization request form for prescription and provider-administered drugs

This document is a multi-section prior authorization (PA) submission form used by prescribers to request coverage for prescription medications, including provider-administered drugs and opioids, and collects patient, prescriber, clinical, and treatment history information required for PA decisions.

Policy Summary

PayerCigna

PolicyPrior authorization request form for prescription and provider-administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProvide requested drug name, strength, dosage form, route, quantity, days' supply, directions, expected therapy duration/start date, HCPCS/CPT-4 code and NDC for provider-administered drugs, primary and secondary diagnosis with ICD-10 codes, pertinent laboratory values and dates, and full treatment history including responses and reasons for failure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8number of form sections

SECTION VIopioid attestation

HCPCS/CPT-4 & NDCprovider-administered coding

EPSDTEPSDT field

Coverage and Attestation Requirements

Submission and attestation requirements

Coverage determination requires completion of all applicable sections and attestations; for opioids additional attestations A–L are required.

Complete submission: Complete prescriber information, patient information, drug information (including HCPCS/CPT-4 and NDC for provider-administered drugs), primary diagnosis with ICD-10 code, and pertinent labs.

Sections I–V must be completed

Pharmacologic history: Provide prior and current pharmacologic and non-pharmacologic treatments with dates, response, and reason for failure; indicate if prerequisite medications are expected to be ineffective or cause adverse reactions.

Section VII

Opioid-specific attestations: For opioid medications, the prescriber must attest to items A–L including assessment, screening, PMP access, treatment plan, opioid treatment agreement, and for long-acting opioids prior short-acting opioid trial and continuous around-the-clock need.

Policy Summary

PayerCigna

PolicyPrior authorization request form for prescription and provider-administered drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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The form explicitly excludes using long-acting opioids to treat acute pain, mild pain, or pain that is not expected to persist for an extended period of time, and excludes prescribing these agents for as‑needed (PRN) use. Requests that indicate a long-acting opioid is intended for any of these purposes are not consistent with the stated prescribing expectations and should be addressed in the clinical justification.

Requests for long-acting opioids must document that the patient requires continuous, around-the-clock analgesic therapy and that alternative treatments have been inadequate or not tolerated. The prescriber must also attest that the patient previously used at least a two‑week trial of short‑acting opioids for the same condition (including drug name, dose, duration and dates recorded in the pharmacologic treatment section). These elements are required in the prescriber attestations (items H and I) to establish clinical necessity for long-acting opioid therapy.

Billing and Diagnosis Codes

Provider-Administered Drug Codesmixed

HCPCS/CPT-4	Field to enter HCPCS or CPT-4 code for provider-administered drugs
NDC	Field to enter drug NDC for provider-administered drugs

Diagnosis CodesICD-10

ICD-10

Primary and secondary diagnosis ICD-10 code fields

inv-06: Cumulative daily MME

Documented cumulative daily MMECumulative daily MME (value entered on form)

Exceeds daily max MME?Indicate yes or no on form: 'Does cumulative daily MME exceed the daily max MME allowed? ___Yes ___No'

If exceeds, provide justificationIf 'Yes', provider must supply justification in the space provided on the form.

Provider Submission Requirements and Risks

Prior Authorization

Submission of drug identifiers and request type

Prior authorization requires completion of drug-specific fields and request type. Provide the requested drug name, strength, dosage form, route of administration, quantity, days' supply, dosage interval/directions, expected therapy duration/start date, and indicate whether this is a new (initial) therapy or a continuation/reauthorization. For provider-administered drugs include HCPCS/CPT-4 code and NDC, dose per administration, and any other applicable billing codes; indicate if the drug will be administered in the physician's office and, if not, provide the servicing provider/facility name and NPI.

Requested Drug Name
Strength
Dosage Form
Route of Admin
Quantity
Days' Supply
Dosage Interval/Directions for Use
Expected Therapy Duration/Start Date
Indicate: New therapy/Initial request OR Continuation of therapy/Reauthorization request
For Provider Administered Drugs: HCPCS/CPT-4 Code
For Provider Administered Drugs: NDC#
Dose Per Administration
Other Codes
Will patient receive the drug in the physician's office? If No, list servicing provider/facility name and NPI

Denial Risk

Denial risk for incomplete documentation

Incomplete or missing information in key fields may result in denial or processing delays. Ensure the form includes prescriber and practice information, patient identifiers, primary diagnosis and ICD-10 code, drug details (name, strength, route, quantity, days' supply), HCPCS/NDC for administered drugs, dates of therapy, and pertinent laboratory values with dates when applicable.

Prescriber information (name, NPI, contact)
Patient identifiers and demographics
Primary diagnosis and ICD-10 code
Date diagnosed
Requested drug name, strength, dosage form, route, quantity, days' supply
HCPCS/CPT-4 and/or NDC for provider-administered drugs
Expected therapy start date and duration
Pertinent laboratory values with dates

Step Therapy

Step therapy / prior treatment documentation

Document prior and current pharmacologic and non-pharmacologic treatments for the relevant diagnosis, including drug name, strength, frequency, dates started and stopped (or approximate duration), response to therapy, reason for failure or allergy, and any pertinent non-pharmacologic interventions. Indicate prior short-acting opioid trials for long-acting opioid requests and note if the plan's step-therapy medications are expected to be ineffective or contraindicated (provide explanation). Include height/weight and list of drug allergies where applicable.

Drug name, strength, frequency
Dates started and stopped or approximate duration
Describe response, reason for failure, or allergy
Drug allergies
Height and weight (if applicable)
Indicate whether plan prerequisite/step medications are expected to be ineffective or cause adverse reaction (explain if Yes)
For long-acting opioids: document prior at least two weeks of short-acting opioid trial (drug, dose, duration, date)

Form Purpose and Scope

This prior authorization form is designed to collect the clinical and administrative details needed to evaluate medical necessity for prescription and provider‑administered medications, including opioids. Section VI captures opioid‑specific attestations about assessment, screening, access to the prescription monitoring program, a documented treatment plan and opioid agreement, and confirmation of prior short‑acting opioid trials and continuous around‑the‑clock analgesic need when long‑acting opioids are requested.

Key Definitions

inv-12: Cumulative daily MME

TermCumulative daily MME

DefinitionThe total daily morphine milligram equivalents (MME) for all opioid medications reported on the form (entered on the 'Cumulative daily MME' line).

Required actionProvider must record the cumulative daily MME and indicate whether it exceeds the daily max MME allowed (Yes/No).

Follow-up if exceededIf cumulative daily MME exceeds the allowed daily max, the form requires the prescriber to provide justification.

Initial Therapy Requirements

Initial therapy requirements

For initial therapy requests, provide full treatment history and justification for initial use.

Initial request indicated: Prescriber must mark 'New therapy/Initial request' on the form and provide expected therapy duration and start date.

Section IV

Prior treatments documented: Document prior and current pharmacologic and non-pharmacologic treatments including drug name, strength, frequency, dates started and stopped or approximate duration, response, and reason for failure.

Section VII

Clinical justification: Provide clinical justification for initiating this therapy in Section VIII if prerequisite medications are expected to be ineffective or cause adverse reaction.

Sections IV, VII, VIII

Continuation and Reauthorization Requirements

Continuation therapy documentation

Continuation/reauthorization requests must be indicated and relevant ongoing therapy details provided.

Continuation request indication: Prescriber must mark 'Continuation of therapy/Reauthorization request' on the form.

Section IV

Current dosing and duration: Provide current dosing, dose per administration (if provider-administered), frequency, days' supply, and duration of ongoing therapy.

Section IV (Prescription Drug Information)

Site of care if applicable: Indicate whether the patient will receive the drug in the physician's office; if not, provide servicing provider/facility name and NPI.

Section IV (Provider Administered Drugs)

Step Therapy Exceptions and Documentation

Step	Requirement	Provider action
1
Document prior and current pharmacologic and non-pharmacologic treatments for the diagnosis, including drug name, strength, frequency, dates started/stopped or approximate duration, response, reason for failure, or allergy.
If the plan's prerequisite medications are expected to be ineffective or to cause an adverse reaction, mark 'Yes' on Section VII and provide a detailed explanation in Section VIII.

Administration Site and Servicing Provider

Note

Specify site of care and provide servicing provider/facility name and NPI if not in office

Indicate in Section IV whether the patient will receive the drug in the physician’s office; if 'No,' provide the name and NPI of the servicing provider or facility in the space provided.

Check 'Yes' or 'No' for in‑office administration.
If 'No', list servicing provider/facility name and NPI on the form.