CurrentCignaPolicy N/A

Ryzneuta (efbemalenograstim alfa) prior authorization / coverage request form

This document is a Cigna prior authorization/coverage request form and clinical checklist for Ryzneuta (efbemalenograstim alfa), used to request pharmacy or medical benefit coverage for patients (including indication options such as chemotherapy prophylaxis, PBPC collection, and radiation syndrome). It applies to providers submitting requests to Cigna.

Policy Summary

PayerCigna

PolicyRyzneuta prior authorization / coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form and attach required clinical documentation (chart notes, lab results, claims or prescription records) to support indication and prior therapy trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

800.882.4462urgent request phone

Accredopreferred specialty pharmacy

Ryzneutadrug on form

Coverage Criteria

Coverage criteria (implied)

Covered when ALL of the following are met (as implied by the form requiring affirmation and documentation):

Chemotherapy-related prophylaxis: If for chemotherapy prophylaxis, patient is receiving myelosuppressive anti-cancer medications associated with a high risk (>=20%) of febrile neutropenia OR is receiving a regimen with <20% risk but has at least one prescriber-identified risk factor for febrile neutropenia; AND the medication is prescribed by or in consultation with an oncologist or hematologist.>=20% or presence of risk factors

Form lists example risk factors and requires oncologist/hematologist involvement for myelosuppressive therapy

Prior neutropenic complication: If receiving myelosuppressive therapy without agents associated with febrile neutropenia risk, coverage may be considered when the patient had a prior neutropenic complication from chemotherapy and did not receive prophylaxis with a colony stimulating factor, and a reduced chemotherapy dose or frequency would compromise treatment outcome.prior neutropenic complication and compromised outcome

Policy Summary

PayerCigna

PolicyRyzneuta prior authorization / coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form and attach required clinical documentation (chart notes, lab results, claims or prescription records) to support indication and prior therapy trials.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Therapy Requirements

Initial therapy requirements (form-based)

Initial therapy considerations collected on the form:

Prescriber specialty: If for chemotherapy prophylaxis, the requested medication should be prescribed by or in consultation with an oncologist or hematologist.oncologist or hematologist involvement

Form contains checkbox confirming oncologist/hematologist involvement

Prior agent trials: Form requests documentation that the patient has tried Rolvedon (eflapegrastim) and/or a pegfilgrastim product (examples listed) as applicable; medical documentation specific to the response must be attached or the request may be denied.trial of Rolvedon or pegfilgrastim products

Pegfilgrastim examples listed on the form (Neulasta, Fulphila, Fylnetra, Nyvepria, Udenyca, Stimufend, Ziextenzo) and explicit instruction to attach supporting documentation

Step Therapy / Prior Trials

Requirement	Details
Prescriber attestation of prior therapy trials	Form asks whether documentation is being provided that the patient has tried Rolvedon (eflapegrastim) and/or one pegfilgrastim product; prescriber must indicate Yes or No and attach patient-specific medical documentation when requested.
Types of required documentation	Documentation may include chart notes, laboratory results, medical test results, claims records, prescription receipts, or other patient-specific information; all documentation must include patient identifying information.
Consequence of missing documentation	The form warns that medical documentation specific to responses must be attached or the request may be denied.
Prescriber specialty/consultation requirement	If for myelosuppressive therapy, the form asks whether the medication is prescribed by or in consultation with an oncologist or hematologist (prescriber must indicate Yes/No).

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required for Ryzneuta

Prior authorization is required using this form for Ryzneuta (efbemalenograstim alfa). Complete the clinical questions on the form about indication, chemotherapy details, and attach required supporting documentation to substantiate the diagnosis and prior therapies. Submit the completed form and attachments via the instructions on the form (eg, CoverMyMeds or SureScripts) to avoid delays.

Complete all asterisked patient and provider identification fields; Cigna will not respond by fax unless required items are completed.
The form asks whether the patient has tried specific alternative agents: Rolvedon (eflapegrastim-xnst) and at least one pegfilgrastim product (Neulasta, Fulphila, Fylnetra, Nyvepria, Udenyca, Stimufend, Ziextenzo). Provide documentation of prior use when indicated.
Attach patient-specific medical documentation (chart notes, laboratory results, medical test results, claims records, prescription receipts, or similar) that demonstrates diagnosis, neutropenic complications, prior therapies tried, and prescriber consultation when required.
Requests may be denied if required medical documentation demonstrating prior therapy or indication is missing — include identifying patient information on all documents.
If receiving myelosuppressive therapy, confirm whether the patient had a neutropenic complication from prior chemotherapy without prophylactic colony stimulating factor and whether reduced chemotherapy dose/frequency would compromise outcomes.
If receiving myelosuppressive therapy, confirm that the medication is prescribed by or in consultation with an oncologist or hematologist and attach supporting documentation.
If for radiation syndrome, confirm prescription by or consultation with a physician experienced in treating acute radiation syndrome.

Step Therapy

Requested Prior Trials

The form specifically requests documentation that the patient has tried Rolvedon and one pegfilgrastim product when applicable. Medical documentation specific to your response must be attached to the case or the request may be denied.

Rolvedon (eflapegrastim-xnst) — attach chart notes, claims, or prescription receipts if marked Yes.
Pegfilgrastim products (Neulasta, Fulphila, Fylnetra, Nyvepria, Udenyca, Stimufend, Ziextenzo) — attach documentation if marked Yes.

Documentation Required

Required Supporting Clinical Documentation

Attach patient-specific medical documentation to substantiate the diagnosis, risk factors for febrile neutropenia, prior neutropenic complications, prior colony stimulating factor therapy, chemotherapy regimen details, and any specialist consultation. Documentation may include chart notes, lab results, test results, claims records, and prescription receipts. All documentation must include patient-identifying information.

Examples: chart notes documenting febrile neutropenia or neutropenic complication, laboratory neutrophil counts, chemotherapy orders showing regimen and dose intensity, claims or prescription records showing prior CSF use.
If indicating prior use of Rolvedon or a pegfilgrastim product, include dates and supporting records.
Failure to provide these documents may result in denial of the request.

Note

Administrative Documentation

Complete all asterisked patient and provider identification fields on the form. Cigna will not respond by fax with the outcome of the review unless these required items are completed. Use the online submission options (CoverMyMeds or SureScripts) to save time.

Required patient fields include: patient name, Cigna ID, date of birth, patient address, and phone.
Required provider fields include: physician name, specialty, and DEA, NPI or TIN; include office contact, phone, and fax.
Standard response time is 5 business days; call to expedite if urgent.

Denial Risk

Documentation Required to Avoid Denial

Requests may be denied if required medical documentation is missing. Ensure all attachments clearly demonstrate the indication and any prior therapies required by the form.

Denied when documentation of prior therapy (eg, Rolvedon or pegfilgrastim) or evidence of neutropenic complication is not provided but indicated on the form.
Attach documents with patient identifiers to avoid processing delays or denials.

Definitions and Drug Examples

Ryzneuta (efbemalenograstim alfa) — Key facts

Product nameRyzneuta (efbemalenograstim alfa)

Drug classColony stimulating factor

Indications listed on formChemotherapy-induced febrile neutropenia prophylaxis; Peripheral blood progenitor cell (PBPC) collection and therapy; Hematopoietic acute radiation syndrome (H-ARS)

Prior authorization requirementPrior authorization required using this Cigna form with clinical questions about indication, chemo risk level, risk factors, and prior CSF use

Documentation noteAttach patient-specific documentation (chart notes, lab results, claims records, prescription receipts) as requested on the form

Pegfilgrastim products (examples) and step-therapy note

Example pegfilgrastim productsNeulasta, Fulphila, Fylnetra, Nyvepria, Udenyca, Stimufend, Ziextenzo

Form requirement for prior trialForm asks whether documentation is provided that the patient has tried one pegfilgrastim product; medical documentation must be attached or request may be denied

Documentation examplesChart notes, laboratory results, medical test results, claims records, prescription receipts (must include patient-identifying information)

Related alternative mentioned elsewhere on formRolvedon (eflapegrastim-xnst) may also be requested as prior agent trial

OpenPayer