CurrentCignaPolicy N/A

Sylatron (peginterferon alfa-2b) prior authorization / coverage request form

This document is a Cigna prior authorization / coverage request form for Sylatron (peginterferon alfa-2b) used to treat listed diagnoses; it governs submission requirements and clinical information needed from prescribers seeking coverage. Applies to Cigna prescription drug benefit requests.

Policy Summary

PayerCigna

PolicySylatron (peginterferon alfa-2b) prior authorization / coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required patient and prescriber identifiers, requested Sylatron kit, dose/quantity, duration, ICD-10 diagnosis, and clinical rationale; fax to (855) 840-1678 or submit online.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

faxsubmit via

urgent numberurgent phone

listeddiagnosis options

4 listedkit options

Coverage Criteria

Prior Authorization Submission Criteria

Authorization decision based on completed form and clinical justification; prescriber must document ALL relevant items requested

Required submission elements: Provide physician and patient identifiers (including DEA, NPI or TIN), specify Sylatron kit and dose, duration of therapy, ICD-10 diagnosis, and indicate whether therapy is chronic/long-term.

Required fields are marked with asterisk on form.

Diagnosis options: Indicate one or more applicable diagnoses: chronic myelogenous leukemia (CML), giant cell tumor of the bone (GCTB), melanoma, myelofibrosis/myeloproliferative disease, or other (specify).

Form contains checkboxes for these diagnoses.

Condition-specific clinical info: For CML, document inability to tolerate listed tyrosine kinase inhibitors or post-transplant relapse; for GCTB, indicate whether Sylatron will be used as single-agent therapy; provide additional pertinent information including labs, disease stage, prior therapy and dosing.

Policy Summary

PayerCigna

PolicySylatron (peginterferon alfa-2b) prior authorization / coverage request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Sylatron. Complete the prior authorization form and fax to (855) 840-1678 or submit online via www.covermymeds.com or SureScripts in your EHR. If this is an URGENT request, call (800) 882-4462 (800.88.CIGNA). Our standard response time is 5 business days; urgent requests should be called to expedite processing.

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
Urgent request phone: (800) 882-4462

Step Therapy

Step Therapy / Prior Treatment

No formal step therapy or prior-failure sequencing rules are listed on the form. Document prior therapies and clinical history fully on the request (including specific agents tried and reason for discontinuation) so the reviewer can assess prior treatment adequacy.

List prior therapies (e.g., Gleevec, Sprycel, Tasigna, Bosulif) and indicate intolerance or failure where applicable
If patient is post-transplant and relapsed, document transplant history and relapse details

Documentation Required

Required Submission Content & Incomplete Fields

Submit a completed prior authorization form with all required patient and prescriber identifiers. Incomplete forms lacking any asterisked (*) patient or physician items will prevent response via fax and may delay or impede processing.

Required prescriber identifiers: DEA, NPI or TIN
Required patient identifiers: Cigna ID, patient name, date of birth, patient address
Complete all asterisked (*) fields on the form to ensure a fax response and timely processing
Include clinical information: diagnosis (ICD-10), dose, quantity, duration, prior therapies, relevant labs, disease stage, performance status, and concurrent medications
Prescriber signature and date required

Step	Requirement
1	Form requests prior therapy details but does not require a specific step-therapy sequence; for CML the prescriber should indicate inability to tolerate listed TKIs (Gleevec, Sprycel, Tasigna, Bosulif) or post‑transplant relapse, and provide additional pertinent clinical information in the Additional Pertinent Information section.

Background

Sylatron (peginterferon alfa-2b) is an oncology-directed interferon formulation referenced on the Cigna prior authorization form under the trade name Sylatron (peginterferon alfa-2b). The form lists several potential indications that may be considered when evaluating medical necessity, including chronic myelogenous leukemia (CML), giant cell tumor of the bone (GCTB), melanoma, and myelofibrosis/myeloproliferative disease, and it requests supporting clinical details to justify use.

Providers are required to submit a completed prior authorization form that identifies the requested Sylatron kit, dose, quantity and duration, the applicable ICD-10 diagnosis, and relevant clinical information (for example, prior therapies, intolerance to listed TKIs for CML, post‑transplant relapse, or whether Sylatron will be used as single-agent therapy for GCTB). The form indicates required fields with an asterisk and requests additional pertinent information such as labs, disease stage, prior therapy, and dosing/schedule for concurrent agents to support the coverage review.

Submission instructions on the form state to fax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts in the EHR. The form also provides an urgent request phone number: (800) 882-4462 and notes that the standard response time for prescription drug coverage requests is 5 business days.

The form does not contain explicit numeric dosing limits, quantity limits, or automated approval criteria; instead, authorization decisions are made based on the completed form and clinical justification provided by the prescriber. Because required items are asterisked, missing required patient or prescriber fields may prevent a fax response and impede processing, so ensure all asterisked fields are completed prior to submission.

OpenPayer

Sylatron (peginterferon alfa-2b) prior authorization / coverage request form

Coverage Criteria

Initial Therapy Criteria

Provider Actions & Submission Requirements

Coding & Kit Options

Prior Therapy / Step Therapy Information

Background

Definitions