CurrentCignaPolicy N/A

Leuprolide (Camcevi, Eligard, Vabrinty) prior authorization form

This document is a Cigna prior authorization request form for leuprolide products (Camcevi, Eligard, Vabrinty) used by prescribers to request coverage for patients (e.g., prostate cancer, salivary gland tumors). It governs submission requirements and clinical fields needed for review.

Policy Summary

PayerCigna

PolicyLeuprolide (Camcevi, Eligard, Vabrinty) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form (fax or online) with required patient and prescriber information, diagnosis, dosing, and clinical justification.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

Fax: (855) 840-1678fax number to submit completed form

Accredo 4436920preferred specialty pharmacy identifier

Coverage Determination Criteria

Information required to assess medical necessity

Coverage determination requires submission of the following clinical data for review:

Required form fields: Completed patient and prescriber identifiers (asterisked items), medication selection, ICD-10 diagnosis, dose/quantity/duration, and site of supply must be provided.

See form fields in chunks 2,4,5

Diagnosis-specific items for prostate cancer: Indicate diagnosis (prostate cancer) and whether disease is advanced (Yes/No).

Chunk 7-8

Diagnosis-specific items for salivary gland tumors when Eligard requested: Indicate if Eligard will be used as single-agent systemic therapy, androgen receptor-positive status, recurrent disease, presence of distant metastases with performance status 0-3, or unresectable locoregional recurrence/second primary with prior radiation therapy.

Policy Summary

PayerCigna

PolicyLeuprolide (Camcevi, Eligard, Vabrinty) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form (fax or online) with required patient and prescriber information, diagnosis, dosing, and clinical justification.

SourceLink

On This Page

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Coverage determination for leuprolide products is driven by the clinical information submitted on the completed prior authorization form. The form collects disease-specific items (for example, whether prostate cancer is advanced, and for salivary gland tumors whether Eligard will be used as single-agent systemic therapy, androgen receptor status, recurrent disease, distant metastases with performance status, or unresectable locoregional recurrence/second primary after prior radiation) and asks for additional clinical information and relevant labs to support the request. Providers should complete all required patient and prescriber identifiers, medication selection, ICD-10 diagnosis, directions/dose/quantity/duration, and site of supply to allow Cigna to assess medical necessity.

Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Camcevi, Eligard, and Vabrinty. Submit prior authorization requests using the methods below. Include all required patient and prescriber fields; incomplete asterisked (*) items will prevent Cigna from responding via fax with the outcome.

Submission methods: Save time — submit online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.
Phone/fax options: Accredo e-prescribe (NCPDP 4436920), Accredo fax 888.302.1028, Accredo verbal 866.759.1557.

Documentation Required

Provider Action — Indicate Where Medication Will Be Obtained

Providers must indicate where the medication will be obtained on the request form. Accredo is Cigna's nationally preferred specialty pharmacy.

Options to select: Accredo Specialty Pharmacy; Prescriber's office stock (billing on a medical claim form); Retail pharmacy; Home healthcare; Other (specify).
Accredo contact details: 1620 Century Center Pkwy, Memphis, TN 38134-8822; NCPDP 4436920; Fax 888.302.1028; Verbal 866.759.1557.

Documentation Required

Provider Action — Complete Patient/Prescriber & Medication Details

Complete all patient and prescriber identifying fields and clinical details on the form. Provide diagnosis (ICD-10), medication requested (include product and strength), directions for use, dose, quantity, and duration of therapy.

Required patient/prescriber fields include: Physician name, Specialty, DEA/NPI/TIN, Office contact person, Office phone, Office fax, Office street address, City/State/Zip, Patient name, Cigna ID, Date of birth, Patient street address, City/State/Zip, Patient phone.
Medication request details: check the specific product (Camcevi, Eligard doses, Vabrinty doses, or specify other), include ICD-10 code, directions for use, dose, quantity, and duration of therapy.

Denial Risk

Incomplete Required Items Will Prevent Fax Response

If the form is missing any required asterisked (*) items, Cigna will be unable to respond via fax with the outcome. Ensure all asterisked fields are completed before submission to avoid delay.

Asterisked required items include: Physician name*, DEA/NPI/TIN*, Patient name*, Cigna ID*, Date of birth*, Patient street address*.

Form Fields & Definitions

Advanced disease (prostate cancer)

FieldAdvanced disease (prostate cancer): Yes / No

PurposeAsked when diagnosis is prostate cancer to inform therapy appropriateness

Action for providerSelect Yes or No on the form under Clinical Information when prostate cancer is the diagnosis

Eligard use in salivary gland tumors

Eligard single-agent useWill this drug be used as single-agent systemic therapy? — Yes / No

Androgen receptor statusDoes the patient have androgen receptor-positive disease? — Yes / No

Recurrent diseaseDoes the patient have recurrent disease? — Yes / No

Metastases and performance statusDoes the patient have distant metastases and a performance status (PS) of 0-3? — Yes / No

Unresectable locoregional recurrence/second primaryIf no distant metastases, indicate unresctable locoregional recurrence or second primary with prior radiation therapy — Yes / No

Camcevi 42 mg	Camcevi 42 mg emulsion for injection kit
Eligard 7.5 mg	Eligard 7.5 mg
Eligard 22.5 mg	Eligard 22.5 mg
Eligard 30 mg	Eligard 30 mg
Eligard 45 mg	Eligard 45 mg
Vabrinty 22.5 mg	Vabrinty 22.5 mg syringe kit
Vabrinty 30 mg	Vabrinty 30 mg syringe kit
Vabrinty 45 mg	Vabrinty 45 mg syringe kit

OpenPayer

Leuprolide (Camcevi, Eligard, Vabrinty) prior authorization form

Coverage Determination Criteria

Requested Medications / Codes

Provider Submission Requirements & Actions

Clinical Background

Form Fields & Definitions