Cigna prior authorization, page 45

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
Q5121	Injection, infliximab-axxq, biosimilar, (avsola), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5122*	Injection, pegfilgrastim-apgf (nyvepria), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5123*	Injection, rituximab-arrx, biosimilar, (riabni), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5124	Injection, ranibizumab-nuna, biosimilar, (byooviz), 0.1 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5125*	Injection, filgrastim-ayow, biosimilar, (releuko), 1 microgram	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5126*	Injection, bevacizumab-maly, biosimilar, (alymsys), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5127*	Injection, pegfilgrastim-fpgk (stimufend), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5128	Injection, ranibizumab-eqrn (cimerli), biosimilar, 0.1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5129*	Injection, bevacizumab-adcd (vegzelma), biosimilar, 10 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5130*	Injection, pegfilgrastim-pbbk (fylnetra), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5133	Injection, tocilizumab-bavi (tofidence), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5134	Injection, natalizumab-sztn (tyruko), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5135	Injection, tocilizumab-aazg (tyenne), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5136	Injection, denosumab-bbdz (jubbonti/wyost), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5137	Injection, ustekinumab-auub (wezlana), biosimilar, subcutaneous, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5138	Injection, ustekinumab-auub (wezlana), biosimilar, intravenous, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5140	Injection, adalimumab-fkjp, biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5141	Injection, adalimumab-aaty, biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5142	Injection, adalimumab-ryvk biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5143	Injection, adalimumab-adbm, biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5144	Injection, adalimumab-aacf (idacio), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5145	Injection, adalimumab-afzb (abrilada), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5146*	Injection, trastuzumab-strf (hercessi), biosimilar, 10 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5147	Injection, aflibercept-ayyh (pavblu), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5148*	Injection, filgrastim-txid (nypozi), biosimilar, 1 microgram	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5149	Injection, aflibercept-abzv (enzeevu), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5150	Injection, aflibercept-mrbb (ahzantive), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5151	Injection, eculizumab-aagh (epysqli), biosimilar, 2 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5152	Injection, eculizumab-aeeb (bkemv), biosimilar, 2 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5153	Injection, aflibercept-yszy (opuviz), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5154	Injection, omalizumab-igec (omlyclo), biosimilar, 5 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5155	Injection, aflibercept-jbvf (yesafili), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5156*	Injection, tocilizumab-anoh (avtozma), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5157*	Injection, denosumab-bmwo (stoboclo/osenvelt), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 99 Original policy
Q5158*	Injection, denosumab-bnht (bomyntra/conexxence), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5159*	Injection, denosumab-dssb (ospomyv/xbryk), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5160*	Injection, bevacizumab-nwgd (jobevne), biosimilar, 10 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5161*	Injection, denosumab-kyqq (aukelso/bosaya), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5162*	Injection, denosumab-nxxp (bildyos/bilprevda), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5164	Injection, ustekinumab-hmny (starjemza), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5165*	Injection, denosumab-mobz (oziltus), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5166*	Injection, denosumab-desu (osvyrti/jubereq), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5167*	Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5168	Injection, ranibizumab-leyk (nufymco), biosimilar, 0.1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5169*	Injection, pegfilgrastim-unne (armlupeg), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5170	Injection, aflibercept-boav (eydenzelt), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5171*	Injection, denosumab-mobz (boncresa), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5172*	Injection, filgrastim-laha (filkri), biosimilar, 1 microgram	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q5173*	Injection, denosumab-adet (ponlimsi), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy
Q9996	Injection, ustekinumab-ttwe (pyzchiva), subcutaneous, 1 mg	Master Precertification List For Health Care Providers, Pg 100 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.