CurrentCignaPolicy v111525

Patient information / prior-authorization form for pulmonary arterial hypertension (PAH) medications

This Cigna prior-authorization form governs submission requirements for PAH medications (e.g., Uptravi) and applies to prescribers, dispensing sites, and patients receiving PAH therapy.

Policy Summary

PayerCigna

PolicyPatient information / prior-authorization form for PAH medications

Policy CodePolicy v111525

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a prior authorization with medication details, ICD‑10 diagnosis, documentation confirming WHO Group 1 PAH (e.g., right heart catheterization), dispensing source, and supporting medical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UptraviMedication listed

WHO Group 1Diagnosis option

RHCDiagnostic confirmation

5 daysStandard response time

Coverage Criteria

Initial Prior Authorization — WHO Group 1 PAH

Covered when ALL of the following are met:

Documentation and diagnosis confirmation: Right heart catheterization confirming WHO Group 1 pulmonary arterial hypertension (PAH) must be documented and attached.documentation attached

Medical documentation (e.g., chart notes, laboratory tests, claims records) must be attached or the request may be denied.

Prescriber qualifications: The requested medication is prescribed by, or in consultation with, a cardiologist or pulmonologist.

Medication details: Provide medication name, dose, frequency, duration, and dispensing source (e.g., Accredo specialty pharmacy or prescriber office stock); include J‑code if injectable and facility/tax ID when applicable.

Policy Summary

PayerCigna

PolicyPatient information / prior-authorization form for PAH medications

Policy CodePolicy v111525

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Provider Actions & Submission Requirements

Prior Authorization

Prior Authorization Submission Requirements

Prior authorization submission must include the medication name (e.g., Uptravi), ICD-10 diagnosis code, dose/quantity, frequency, duration of therapy, and J‑code if the medication is injectable.

Medication Requested (e.g., Uptravi)
ICD-10 diagnosis
Dose, quantity, frequency, duration
J-code (if injectable)

Note

Dispensing / Fulfillment Source

Indicate the dispensing/fulfillment source for the requested medication. Cigna's nationally preferred specialty pharmacy is Accredo; orders may be placed via E-prescribe (NCPDP 4436920), fax 888.302.1028, or verbal 866.759.1557. Other options to specify include prescriber's office stock (medical claim billing), retail pharmacy, home health/home infusion vendor, or other named source.

Accredo Specialty Pharmacy (Cigna’s nationally preferred specialty pharmacy)
Accredo E-prescribe NCPDP: 4436920
Accredo Fax: 888.302.1028
Accredo Verbal: 866.759.1557
Prescriber's office stock (billing on a medical claim form)
Retail pharmacy
Home Health / Home Infusion vendor
Other (specify)

Documentation Required

Required Supporting Documentation

Attach required supporting clinical documentation to the prior authorization request. Acceptable documentation includes chart notes, laboratory tests, claims records, and procedure reports (e.g., right heart catheterization). If the medication is for PAH, documentation confirming WHO Group 1 PAH and results of right heart catheterization should be included. Ensure records demonstrate specialty consultation (cardiologist or pulmonologist) when applicable.

Chart notes and clinic documentation
Relevant laboratory test results
Claims records
Right heart catheterization reports and results (if applicable)
Documentation confirming WHO Group 1 PAH (when applicable)
Consultation notes from cardiologist or pulmonologist

Denial Risk

Missing Documentation May Trigger Denial

Missing or incomplete supporting documentation (including lack of right heart catheterization report when required, absent diagnosis confirmation, or omission of requested dosing/J‑code information) may result in denial or delay of the prior authorization. Attach all requested records to avoid denial or the need for follow-up requests.

Denial risk if required clinical documentation is not attached
Incomplete submission (missing ICD‑10, dose/quantity, frequency, duration, or J‑code) may delay or deny request
Failure to indicate dispensing/fulfillment source may require follow-up

Background

This patient information/prior authorization form is used to request coverage for pulmonary arterial hypertension (PAH) medications (for example, Uptravi). It prompts the prescriber to confirm whether the diagnosis is WHO Group 1 PAH, whether that diagnosis was confirmed by right heart catheterization, and whether the prescriber is a cardiologist or pulmonologist. The form also asks about current therapy status and specifies that medical documentation must be attached to the case; standard review time for prescription drug coverage requests is 5 business days unless the request is expedited.

Definitions

WHO Group 1 PAH — definition and confirmation

WHO GroupPulmonary arterial hypertension (PAH) specified as World Health Organization (WHO) Group 1 on the form.

Supporting documentationMedical documentation specific to the right heart catheterization must be attached (examples listed: chart notes, laboratory tests, claims records, and/or other information).

Prescriber specialtyForm asks whether the medication is prescribed by or in consultation with a cardiologist or pulmonologist (requested specialty involvement).

Impact of missing documentationThe form warns that requests may be denied if the required medical documentation verifying responses is not attached.

OpenPayer

Patient information / prior-authorization form for pulmonary arterial hypertension (PAH) medications

Coverage Criteria

Coding

Provider Actions & Submission Requirements

Background

Definitions