MEDICARE ADVANTAGE DRUGS/BIOLOGICS PART B
PRECERTIFICATION FORM
PART B STEP THERAPY - NEUPOGEN, GRANIX
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health
and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2019 Cigna
INT_19_81858 926102
Expedited – dened as danger to a patient’s health if not provided within 24 hours
Patient name: Patient date of birth:
Name of requesting provider: ID number:
Contact person: Date of service:
Address:
NPI number: Phone number: Fax number:
If referring to a (servicing) provider, the below stated information must be submitted:
Name of servicing provider: Phone number:
Contact person: Fax number:
Address: NPI number:
Please check if servicing provider is non-contracted
If servicing provider is non-contracted/out-of-network provider/facility, please explain why:
Who will supply the medication?
Provider oce
Outpatient hospital/clinic
Pharmacy not located within
the servicing facility
Please select place of service by checking only one of the boxes:
Provider oce
Outpatient hospital/clinic
Other. Please specify:
Diagnosis codes: Diagnosis:
Please attach all required documentation: recent clinical notes, copy of the prescription or physician order,
relevant diagnostic labs.
HCPCS codes Drug name
(if applicable)
Dose
(if applicable)
Frequency Duration
Q1: Is this a new start or a continuation of therapy within the past 365 days?
Q2: Has the patient had an intolerance or an inadequate response to a Step 1 alternative (Zarxio or Nivestym)?
Q3: If patient is unable to try a Step 1 alternative (Zarxio or Nivestym), please provide the reason(s) why an
exception should be made to the step therapy requirement:
This precertication form applies to all Cigna Medicare markets except Arizona and Leon health plans. This
precertication form does not apply to Medicaid only and Medicare/Medicaid Plan (MMP) plans. Please fax to:
1-877-730-3858 | Phone: 1-888-454-0013
Note: In an eort to process your request in a timely manner, please submit all pertinent clinical information.
