CurrentCignaPolicy N/A

prior_authorization_form_for_specific_medications

This document is a Cigna prior authorization form to collect required patient, prescriber, and clinical information for authorization requests for specific medications (notably inhaled prostacyclins such as Tyvaso) for pulmonary hypertension (WHO Group 1 and Group 3). It specifies required documentation, diagnosis/options, and clinical questions to support a coverage decision.

Policy Summary

PayerCigna

Policyprior_authorization_form_for_specific_medications

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete all asterisked items on the form and attach medical documentation (e.g., chart notes, right heart catheterization reports, baseline FVC, chest CT) to support the PA request; incomplete forms may lead to denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form operationalizes prior authorization information collection for inhaled prostacyclin products.

1Primary medication example listed (Tyvaso)

2Primary diagnosis groups (WHO Group 1 and Group 3)

5Key documented items requested (RHC, FVC, CT, prior therapies, clinician specialty)

Policy summary & purpose

This Cigna prior authorization form is used to authorize inhaled prostacyclin products (for example, Tyvaso) for the treatment of pulmonary hypertension, specifically for WHO Group 1 pulmonary arterial hypertension and WHO Group 3 pulmonary hypertension associated with interstitial lung disease. The form collects clinical information to support a coverage decision, including the specific medication requested, dose/quantity/frequency/duration (and J-code if injectable), and the intended dispensing source.

The form requires prescriber and patient identifiers (physician name, specialty, DEA/NPI/TIN, office contact, patient name, Cigna ID, date of birth, addresses, and phone/fax) and documents clinical justification elements such as diagnostic confirmation via right heart catheterization (RHC), WHO functional class, prior trials of oral, inhaled, or parenteral PAH therapies, and current response to therapy. Completion of all asterisked fields is required for the reviewer to return a faxed outcome.

Operationally, the completed form and attached supporting documentation (e.g., chart notes, catheterization reports, baseline FVC, chest CT) are used during Cigna's prior authorization review to determine coverage for inhaled prostacyclins and to ensure required clinical criteria are met.

Scope summaryThis document is a Cigna prior authorization form to collect required patient, prescriber, and clinical information for authorization requests for specific medications (notably inhaled prostacyclins such as Tyvaso) for pulmonary hypertension (WHO Group 1 and Group 3). It specifies required documentation, diagnosis/options, and clinical questions to support a coverage decision.

Primary medication exampleTyvaso

Primary diagnosis groupsWHO Group 1 PAH; WHO Group 3 (pulmonary hypertension associated with interstitial lung disease)

Key documented items requestedRight heart catheterization (RHC), baseline FVC, chest CT, prior therapies, clinician specialty

Threshold: Baseline FVC< 70% (when connective tissue disease present)

Threshold: RHC requiredDocumentation of right heart catheterization is requested/required depending on scenario (attach chart notes/catheterization reports); prior documentation for a different PAH medication may be considered sufficient.

Information and documentation required for prior authorization requests

Information and documentation required for PA requests

Form requests collection of specific items; completion of all asterisked fields required for response. Clinical questions guide documentation sufficiency.

ALL of the following

Patient and Prescriber Identifiers: Patient and prescriber identifying information must be provided (physician name, specialty, DEA/NPI/TIN, office contact, patient name, Cigna ID, DOB, addresses, phone/fax).
All asterisked items must be completed to receive faxed outcome.
Urgency: Indicate urgency: Standard or Urgent (urgent attestation required if selected).
If 'Urgent' is selected, prescriber must attest that applying standard review time may seriously jeopardize patient's life/health/ability to regain function.
Medication Details: Medication requested must be specified (Tyvaso or Other) and include dose, quantity, frequency, duration, and J‑code if injectable.
Include dose, quantity, frequency, duration, and J-code if injectable.
Medication Source: Specify source of medication (Accredo Specialty Pharmacy preferred, prescriber's office stock, retail, home health/home infusion, or other).
Accredo is Cigna's nationally preferred specialty pharmacy; contact info provided.
Facility/Dispensing Info: Facility/dispensing information for injectable medications must be provided (facility name, state, tax ID).
Facility and/or doctor dispensing and administering medication (if injectable): Facility Name, State, Tax ID#.
Chronic Therapy: Indicate whether medication is for chronic/long-term condition potentially necessary for the life of the patient (Yes/No).
Is the requested medication for a chronic or long-term condition for which the prescription medication may be necessary for the life of the patient?
Diagnosis Selection: Select diagnosis related to use: WHO Group 1 PAH, WHO Group 3 pulmonary hypertension associated with interstitial lung disease, or Other (specify).
Diagnosis related to use must be specified.
Prescriber Specialty: Answer whether prescriber is a cardiologist or pulmonologist (Yes/No).
Is the medication being prescribed by or in consultation with a cardiologist or a pulmonologist?
WHO Group 1 Questions
- Current therapy status: Is the patient currently receiving the requested inhaled prostacyclin? (Yes/No).
- RHC documentation if not currently receiving: If not currently receiving: Provide documentation of right heart catheterization (attach chart notes/cath reports).
  Documentation of RHC is requested to confirm diagnosis prior to initiating therapy; previously provided RHC documentation for another PA may be considered sufficient.
- RHC confirmation: If RHC performed: confirm whether results confirmed WHO Group 1 PAH (Yes/No).
- WHO Functional Class: If not currently receiving: Is the patient in WHO functional Class III or IV? (Yes/No).
  If not Class III/IV: Is the patient Class II? (Yes/No).
WHO Group 3 Questions
- Current therapy status: Is the patient currently receiving the requested medication for pulmonary hypertension associated with interstitial lung disease? (Yes/No).
  A 'yes' answer must be reviewed by UMP/nurse team.
- RHC documentation if not currently receiving: If not currently receiving: Provide documentation of right heart catheterization (attach chart notes/cath reports).
  Documentation of RHC is requested to confirm diagnosis prior to initiating therapy; a 'yes' answer requires UMP/nurse review.
- RHC confirmation: If RHC performed: confirm whether results confirmed WHO Group 3 pulmonary hypertension associated with interstitial lung disease (Yes/No).
- Connective tissue disease: If not currently receiving: Does the patient have connective tissue disease? (Yes/No).
Prescriber Attestation: Prescriber attestation and signature with date required for WHO Group 3 section.
Prescriber signature and date required; attestations for accuracy and audit may be required.
Attachment of Documentation: Attach additional pertinent information and supporting documentation as requested to avoid denial (chart notes, RHC reports, baseline FVC, chest CT).
Incomplete forms or missing documentation may lead to denial.

For WHO Group 1 related questions (apply all below that are relevant depending on current therapy status): Branch node placeholder (children captured above)

For WHO Group 3 related questions (apply all below that are relevant depending on current therapy status): Branch node placeholder (children captured above)

What providers must do

Documentation Required

Submit completed prior authorization form with required documentation

Providers must complete all asterisked items on the form and attach medical documentation (e.g., chart notes, right heart catheterization reports, baseline FVC, chest CT) to support the PA request; incomplete forms may lead to denial.

Chart notes
Right heart catheterization reports
Baseline FVC
Chest CT

Documentation Required

Right heart catheterization documentation

For many scenarios (especially initiation in WHO Group 1 and Group 3), documentation of a prior right heart catheterization is required and must be attached; if prior documentation was provided for a different PA it may be considered sufficient.

Prior documentation submitted for a different PA may be considered sufficient

Documentation Required

Specialty pharmacy preference

If medication will be obtained through Accredo (Cigna's nationally preferred specialty pharmacy), prescriber may place orders via e-prescribe, fax, or phone; selection of Accredo should be indicated on the form.

E-prescribe
Fax (888.302.1028)
Phone (Verbal 866.759.1557)
Indicate Accredo selection on the form

Denial Risk

Urgent request attestation

If 'Urgent' is selected, prescriber must attest that applying the standard review time frame may seriously jeopardize the patient's life/health/ability to regain function; failure to attest appropriately may affect expedited processing.

Failure to attest appropriately may affect expedited processing

Background and definitions

The form operationalizes the prior authorization workflow by specifying urgency options (Standard or Urgent) with an attestation required if Urgent is selected, and by asking where the medication will be obtained, noting that Accredo is Cigna's nationally preferred specialty pharmacy and providing Accredo contact/order methods.

It also captures facility/dispensing details when the medication is administered or billed by a facility, queries whether the therapy is intended for a chronic or lifelong condition, and includes an attestation and prescriber signature (required for WHO Group 3) to verify the accuracy of the submitted information.

Submitters are encouraged to attach all requested documentation and may submit the form online; Cigna's standard response time is 5 business days and urgent cases should be called to expedite processing.

RHCRight heart catheterization; documentation of RHC is requested to confirm diagnosis prior to initiating therapy (attach chart notes or catheterization laboratory reports).

FVCForced vital capacity; baseline FVC <70% is queried when connective tissue disease is present for WHO Group 3 assessments.

OpenPayer

prior_authorization_form_for_specific_medications

Policy summary & purpose

Information and documentation required for prior authorization requests

Billing identifiers and codes

What providers must do

Background and definitions

Document changes