CurrentCignaPolicy v010124

Zaltrap (aflibercept) prior authorization form

This document is a Cigna prior authorization request form for the oncology drug Zaltrap (aflibercept), used to request coverage and provide clinical information for patients (e.g., with colorectal cancer) who may receive infusion therapy. It governs provider submission requirements for medication authorization and site-of-care selection.

Policy Summary

PayerCigna

PolicyZaltrap (aflibercept) prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization via this form (fax to 855-840-1678) or online including vial size, dose, frequency, duration, ICD-10 diagnosis, and required patient and prescriber identifiers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

855-840-1678fax number to submit completed form

Accredonationally preferred specialty pharmacy

Zaltrapmedication covered by this form

Coverage Criteria

Policy Summary

PayerCigna

PolicyZaltrap (aflibercept) prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization via this form (fax to 855-840-1678) or online including vial size, dose, frequency, duration, ICD-10 diagnosis, and required patient and prescriber identifiers.

SourceLink

On This Page

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Initial Therapy Documentation

Initial therapy documentation

Clinical intent and line-of-therapy information must be documented on the form.

Line of therapy: Form requests whether Zaltrap is being given as second-line chemotherapy and whether given in combination with irinotecan

Used to document initial or subsequent-line use; include additional pertinent information such as prior therapy, disease stage, performance status, and names/doses/administration schedule of concurrent agents.

Step / Sequence and Prior Therapies

Prior therapy documented	Second-line?	Combination with irinotecan?	Additional clinical details
Provider records prior therapies (names/doses/admin schedule) as requested on the form	Form asks 'Is Zaltrap being given as second-line chemotherapy?' with Yes/No checkboxes to indicate second-line use	Form asks 'Will Zaltrap be given in combination with irinotecan (Camptosar)?' with Yes/No checkboxes to indicate combination therapy	Free-text field for additional pertinent information including prior therapy, disease stage, performance status, and concurrent agents' names/doses/schedule

Provider Submission & Action Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Zaltrap. Submit requests using the Cigna prior authorization form by fax to 855-840-1678 or online (CoverMyMeds or SureScripts). Include medication vial size, dose, frequency, duration, and planned route/site of administration.

Fax: 855-840-1678
Online: www.covermymeds.com or via SureScripts in your EHR
Include vial size, dose, frequency, duration, and administration details

Step Therapy

Step / Sequence Documentation Required

The form asks whether Zaltrap is being given as second-line chemotherapy and whether it will be combined with irinotecan to document prior treatment sequence and combination therapy. Provide additional pertinent clinical information including prior therapy, disease stage, performance status, and names/doses/schedule of concurrent agents.

Is Zaltrap second-line chemotherapy? (Yes/No)
Will Zaltrap be given with irinotecan? (Yes/No)
Provide prior therapy, disease stage, performance status, and concurrent regimen details

Documentation Required

Provider Submission Requirements & Incomplete Submission Risk

Complete all required patient and provider identifiers. Due to privacy regulations, Cigna will not fax the outcome of the review unless all asterisked (*) items on the form are completed. Incomplete submissions may prevent a response via fax and delay processing.

Patient identifiers: Cigna ID, Date of Birth, Patient name, Patient address, Patient phone
Provider identifiers: Physician name, Specialty, DEA, NPI or TIN, Office contact, Office phone, Office fax, Office address
Incomplete submissions (missing any asterisked items) may prevent a faxed outcome and delay review

Dispensing / Administration Site

Billing Rule

Specify site of supply and dispensing/administration facility

Indicate where the medication will be obtained and the facility that will dispense/administer it; Accredo is listed as Cigna's nationally preferred specialty pharmacy and is an option on the form.

Select one: Accredo Specialty Pharmacy, prescriber's office stock, retail pharmacy, or home infusion
Provide dispensing/administration facility name, address, and Tax ID as requested

Background

This prior authorization form is used to request coverage for Zaltrap (aflibercept), an oncology infusion agent. The form lists colorectal cancer as a selectable diagnosis and asks whether the patient has advanced, unresectable, or metastatic disease, whether Zaltrap is being given as second-line chemotherapy, and whether it will be combined with irinotecan. The form also requests clinical details to support medical necessity, including prior therapy, disease stage, and performance status, and requires a prescriber attestation and signature.

Providers must submit required patient and prescriber identifiers (asterisked items), the requested medication vial size and dosing details, ICD-10 diagnosis, and site-of-care information. The form provides vial options for Zaltrap and asks where the medication will be obtained (including Accredo Specialty Pharmacy, prescriber office stock, retail, or home infusion).

Fax submission is available (complete form to 855-840-1678) or online submission via the listed portal, and the plan’s standard response time for prescription drug coverage requests is 5 business days. The form warns that incomplete submissions—especially omission of asterisked items—may prevent a faxed response.

Zaltrap 100mg/4ml	medication vial option listed on form
Zaltrap 200mg/8ml	medication vial option listed on form

OpenPayer