CurrentAetnaPolicy N/A

Jemperli (dostarlimab-gxly) medication precertification request form

Precertification form used by Aetna to collect clinical, demographic, and treatment details for prior authorization/review of dostarlimab-gxly (Jemperli) across multiple oncology indications.

Policy Summary

PayerAetna

PolicyJemperli (dostarlimab-gxly) medication precertification request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete and submit this 3-page precertification request with all required clinical information and sign the acknowledgement; Aetna may request additional information to evaluate requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multipleindications captured on form (e.g., endometrial, colorectal, ovarian, gastric, breast, solid tumors, etc.)

3 pagesform length

1-866-752-7021Aetna precertification phone

Policy snapshot

This 3-page precertification form is specific to dostarlimab-gxly (Jemperli) and is used by Aetna to collect the required information for prior authorization review across multiple oncology indications. The form captures patient demographics including weight and height, prescriber and dispensing/provider details (NPI, state license, place of administration, pharmacy/infusion center), and indication‑specific clinical data such as tumor type and MSI-H/dMMR testing status. It also documents prior therapy history (including prior PD‑1/PD‑L1 exposure and prior chemotherapy where relevant), safety and infusion considerations (adverse events, venous access or medical instability), and the items required for continuation requests (evidence of toxicity or progression, infusion setting, maintenance combination therapy, and duration of treatment).

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Clinical information and decision trees

Clinical information required for all requests

The request must include documentation of the following:

ALL of the following

Has the patient experienced disease progression while receiving another PD-1 or PD-L1 inhibitor (e.g., nivolumab, pembrolizumab)?
Yes/No must be provided
Primary and secondary ICD diagnosis codes must be provided
Primary ICD Code and any other applicable codes
Complete patient demographics and weight/height
Weight (lbs or kgs) and height (inches or cms) required
Prescriber/licensure and dispensing/provider information
Includes NPI, state license, place of administration, pharmacy/infusion center details

Indication-specific initiation information

For initiation requests, the form collects indication-specific items; coverage decision will be based on these documents (answers are required for each applicable indication):

Select the applicable tumor type and provide the associated fields

Ampullary adenocarcinoma: single-agent use (Yes/No), clinical setting (advanced/recurrent/other), place in therapy (first-line/subsequent), MSI-H/dMMR status, has disease progressed on or following prior treatment (Yes/No), availability of alternative satisfactory treatment options
Breast cancer: clinical setting (recurrent unresectable/Stage IV/other), MSI-H/dMMR status, prior progression (Yes/No), availability of alternative options (Yes/No), single-agent use (Yes/No)
Colorectal cancer (including appendiceal adenocarcinoma): clinical setting (metastatic/advanced/other), place in therapy (first-line/subsequent), MSI-H/dMMR status, prior oxaliplatin/irinotecan/and/or fluoropyrimidine-based therapy received (Yes/No), single-agent use (Yes/No)
Endometrial carcinoma: will medication be used in combination with carboplatin and paclitaxel (Yes/No), clinical setting (recurrent/Stage III-IV), MSI-H/dMMR status, prior progression on a platinum-containing regimen (Yes/No)

Continuation requests

For continuation of therapy, documentation must include:

ALL of the following

Evidence of unacceptable toxicity or disease progression while on the current regimen (Yes/No)
Whether infusion request is in an outpatient hospital setting (Yes/No)
Whether patient is continuing on a maintenance regimen that includes provider-administered combination chemotherapy (Yes/No). If yes, indicate regimen.
If yes, indicate regimen
Whether the patient is experiencing severe toxicity requiring continuous monitoring (e.g., Grade 2-4 bullous dermatitis, transaminitis, pneumonitis, Stevens-Johnson syndrome, acute pancreatitis, primary adrenal insufficiency, aseptic meningitis, encephalitis, transverse myelitis, myocarditis, pericarditis, arrhythmias, impaired ventricular function, conduction abnormalities).
If yes, explanation required

Infusion safety / special circumstances

Form requires documentation of events or conditions that may affect place of service:

ALL of the following

Adverse event with the requested product not responsive to conventional interventions or a severe adverse event during/immediately after infusion (Yes/No). If yes, explanation required.
If yes, explanation required
Severe venous access issues requiring special interventions available only in outpatient hospital setting (Yes/No). If yes, explanation required.
If yes, explanation required
Significant behavioral issues and/or physical or cognitive impairment impacting infusion safety and lack of caregiver (Yes/No). If yes, explanation required.
If yes, explanation required
Medical instability that may limit tolerance of infusion volume and cannot be managed in alternate settings (Yes/No). If yes, describe cardiopulmonary/respiratory/renal/other issues.

What providers must do

Prior Authorization

Complete precertification form for Jemperli

Providers must complete and submit the full 3-page JEMPERLI precertification request and sign the acknowledgement; the plan may request additional information or clarification as needed to evaluate requests.

Documentation Required

Indication-specific clinical documentation

For both initiation and continuation requests, include indication-specific clinical fields such as tumor type, MSI-H/dMMR status, prior therapies, clinical setting and place in therapy, prior PD-1/PD-L1 treatment history, and details on toxicity or medical/infusion instability when applicable.

Tumor-specific fields (e.g., clinical setting, place in therapy, single-agent vs combination use)
MSI-H/dMMR testing status where asked on the form
Prior therapy history including prior PD-1/PD-L1 inhibitors and prior chemotherapies (e.g., oxaliplatin, irinotecan, fluoropyrimidines, platinum regimens)
Details of toxicity or instability (e.g., severe infusion reactions, need for continuous monitoring, venous access issues)

Denial Risk

Incomplete forms risk denial

All fields on the precertification form must be completed and legible; missing or illegible required clinical documentation may result in non-approval or a request for additional information.

Clinical and administrative background

The form’s role is to collect complete, legible information for Aetna’s prior authorization review: demographics (name, DOB, contact, weight and height), prescriber/licensure and contact details (including NPI, state license and specialty), and dispensing/administration details (place of administration, dispensing provider, and CPT administration codes). It includes indication‑specific fields to document tumor type, clinical setting, MSI‑H/dMMR status, prior therapy and progression, and whether the drug will be used as a single agent or in combination. The form also collects safety and infusion items such as prior adverse events or severe reactions during infusion, severe venous access issues, behavioral or caregiver limitations, and medical instability that may affect the appropriate place of service. For continuation requests the form requires documentation of unacceptable toxicity or disease progression while on therapy, whether the infusion is in an outpatient hospital setting, any maintenance combination chemotherapy regimen, specific severe toxicities that require continuous monitoring, and how many continuous months of treatment the patient has received.

OpenPayer

Jemperli (dostarlimab-gxly) medication precertification request form

Policy snapshot

Clinical information and decision trees

Diagnosis and administration codes

What providers must do

Key terms

Clinical and administrative background

Policy updates

	Primary ICD Code (to be provided on form)
	Secondary ICD Code (optional)
	Other ICD Code (optional)