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The form requests information on clinical use for chemotherapy-induced nausea and vomiting, combination with dexamethasone, chemotherapy regimen and emetic risk, and whether additional antiemetics apply. It also captures where the medication will be obtained and infusion setting details, ending with prescriber attestation and signature.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sustol-prior-authorization-form/283768/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sustol-prior-authorization-form/283768.png","ImageObject",442,249,{"name":88,"@type":89},"Chumphorn","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Where should the completed form be sent and what contact options are provided for urgent requests?","Question",{"text":109,"@type":110},"Fax the completed form to (855) 840-1678. For urgent requests, call (800) 882-4462.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which patient and physician details are required before submission?",{"text":114,"@type":110},"The form requests physician name, specialty, DEA/NPI/TIN, office contact and phone/fax, plus patient name, Cigna ID, date of birth, and full address and phone. It also notes that all asterisked items on the form must be completed to respond via fax with review outcomes.",{"name":116,"@type":107,"acceptedAnswer":117},"What clinical information must be provided regarding Sustol’s use?",{"text":118,"@type":110},"The form asks whether Sustol is used for chemotherapy-induced nausea and vomiting, whether it will be used with dexamethasone, whether the patient receives IV chemotherapy, and the IV chemotherapy emetic risk level. It also requests additional antiemetic medications if the risk is high and asks for the chemotherapy drugs, doses, and administration schedules.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283768,1790406660,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336475401981,"https://ap-avatar.wpscdn.com/avatar/22000c94efd8d5204d?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786935347598174694","Fax completed form to: (855) 840-1678  \nIf this is an URGENT request, please call (800) 882-4462  \n(800.88.CIGNA)  \nSustol  \n(granisetron)  \n\n| PHYSICIAN INFORMATION |  |  |  | PATIENT INFORMATION |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| * Physician Name: |  |  |  | *Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked (*) items on this form are completed. * |  |  |  |\n| Specialty: |  | * DEA, NPI or TIN: |  |  |  |  |  |\n| Office Contact Person: |  |  |  | * Patient Name: |  |  |  |\n| Office Phone: |  |  |  | * Cigna ID: |  | * Date of Birth: |  |\n| Office Fax: |  |  |  | * Patient Street Address: |  |  |  |\n| Office Street Address: |  |  |  | City: | State: |  | Zip: |\n| City: | State: |  | Zip: | Patient Phone: |  |  |  |\n| Urgency:\u003Cbr> Standard  Urgent (In checking this box, I attest to the fact that applying the standard review time frame may\u003Cbr>seriously jeopardize the customer’s life, health, or ability to regain maximum function) |  |  |  |  |  |  |  |\n| Medication Requested:  Sustol  Other (please specify):\u003Cbr>Directions for use: Dose: Quantity:\u003Cbr>Duration of therapy: ICD10: JCode: |  |  |  |  |  |  |  |\n| Where will this medication be obtained?\u003Cbr> Accredo Specialty Pharmacy**\u003Cbr> Prescriber’s office stock (billing on a medical claim form)  Other (please specify): |  |  |  |  Retail pharmacy\u003Cbr> Home Health / Home Infusion vendor\u003Cbr>**Cigna’s nationally preferred specialty pharmacy |  |  |  |\n| **Medication orders can be placed with Accredo via E-prescribe-Accredo (1620 Century Center Pkwy, Memphis, TN 38134-8822 | NCPDP 4436920), Fax 888.302. 1028, or Verbal 866.759.1557 |  |  |  |  |  |  |  |\n| Facility and/or doctor dispensing and administering medication:\u003Cbr>Facility Name: State: Tax ID\\#:\u003Cbr>Address (City, State, Zip Code) :\u003Cbr>NOTE: Per some Cigna plans, infusion of medication MUST occur in the lowest cost, medically appropriate setting\u003Cbr>.\u003Cbr>Is this infusion occurring in a facility affiliated with hospital outpatient setting?  Yes  No\u003Cbr>If yes- Is this patient a candidate for re-direction to an alternate setting after 1-2 infusions (such as AIS, MDO, home) with assistance of a Specialty Care Option Case Manager?  Yes  No (provide medical necessity rationale): |  |  |  |  |  |  |  |\n| Is the requested medication for a chronic or long-term condition for which the prescription medication may be necessary for the life of\u003Cbr>the patient?  Yes  No |  |  |  |  |  |  |  |\n| Clinical Information\u003Cbr>Is Sustol being used to prevent chemotherapy-induced nausea and vomiting (CINV)? Yes  No \u003Cbr>Will Sustol be used in combination with dexamethasone? Yes  No \u003Cbr>Is your patient receiving IV (intravenous) chemotherapy? Yes  No \u003Cbr>(if yes) What is the emetic risk (risk of vomiting) of this IV chemotherapy?  high risk (over 90% frequency of vomiting)\u003Cbr> moderate risk (30-90% frequency of vomiting)\u003Cbr> low risk (10-30% frequency of vomiting)\u003Cbr> minimal risk (less than 10% frequency of vomiting)\u003Cbr>(if high risk) Will your patient also be given any of the following: aprepitant (oral Emend), fosaprepitant (IV Emend), Varubi?\u003Cbr>Yes  No \u003Cbr>Please list all chemotherapy drugs that patient is receiving. Include names of the drugs, doses, and administration schedules: |  |  |  |  |  |  |  |\n\n\n| Additional pertinent information: (including alternatives tried) |\n| --- |\n| Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan or insurer its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the\u003Cbr>information reported on this form.\u003Cbr>Prescriber Signature:  Date:  |\n| Save Time! [Submit Online at:](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts)[ ](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts)[www.covermymeds.com/ma","cbCaimTliMwLoSiw","https://ap.wps.com/l/cbCaimTliMwLoSiw","pdf",283068,"English","# Physician Information\n## Patient Information\n# Medication Requested\n# Where Will This Medication Be Obtained\n## Facility and Dispensing/Administration Details\n# Clinical Information\n# Additional Pertinent Information\n# Attestation","[{\"question\":\"Where should the completed form be sent and what contact options are provided for urgent requests?\",\"answer\":\"Fax the completed form to (855) 840-1678. For urgent requests, call (800) 882-4462.\"},{\"question\":\"Which patient and physician details are required before submission?\",\"answer\":\"The form requests physician name, specialty, DEA/NPI/TIN, office contact and phone/fax, plus patient name, Cigna ID, date of birth, and full address and phone. It also notes that all asterisked items on the form must be completed to respond via fax with review outcomes.\"},{\"question\":\"What clinical information must be provided regarding Sustol’s use?\",\"answer\":\"The form asks whether Sustol is used for chemotherapy-induced nausea and vomiting, whether it will be used with dexamethasone, whether the patient receives IV chemotherapy, and the IV chemotherapy emetic risk level. It also requests additional antiemetic medications if the risk is high and asks for the chemotherapy drugs, doses, and administration schedules.\"}]","Sustol Prior Authorization Form | PDF",1789619010]