CurrentAetnaPolicy N/A

Briumvi (ublituximab-xiiy) Medication Precertification Request Form

This document is Aetna's medication precertification request form for Briumvi used in multiple sclerosis; it governs information providers must submit to request initiation or continuation of Briumvi for Aetna members.

Policy Summary

PayerAetna

PolicyBriumvi (ublituximab-xiiy) Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest precertification from Aetna prior to outpatient infusion or continuation and submit the completed form with required clinical and administrative information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

Requiredcompletion requirement

1-866-752-7021precert phone

1-888-267-3277precert fax

Coverage & Medical Necessity Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission completeness: All fields on the precertification request form are completed and legible.

Form header: All fields must be completed and legible for precertification review.

Patient and insurance data: Provide patient demographics (name, DOB, address, contact), current weight, allergies, Aetna member ID and other coverage/Medicare/Medicaid IDs if applicable.

Patient information section (weight, contact, identifiers) required.

Prescriber and administration details: Provide prescriber name, credentials, specialty, NPI, phone/fax, dispensing provider and place of administration, and administration CPT code(s) as applicable.

Prescriber and dispensing/provider administration fields must be completed.

Product and dosing: Specify Briumvi (ublituximab-xiiy) dose and frequency and indicate whether this is a new therapy request or a continuation (include date of last treatment for continuations).

Product information section requests dose, frequency and start/continuation status.

Clinical MS information: Document MS type (relapsing forms, clinically isolated syndrome, or other), concomitant disease‑modifying therapy use, neurologist involvement, current use of samples/assistance programs, and prior therapy status (indicate whether Tysabri and Ocrevus were ineffective, not tolerated, or contraindicated).

Clinical information section requires MS subtype, concomitant DMT, neurologist consult, sample assistance, and prior therapy history.

Pediatric attestation (if applicable): For patients 17 years of age or younger, prescriber attestation that benefits outweigh risks must be provided.

Specific pediatric attestation required for <18 (chunk 11).

Infusion setting justification: If the infusion is requested in an outpatient hospital setting OR if the patient has severe venous access issues, significant behavioral/physical/cognitive impairment without caregiver, or medical instability (cardiovascular, respiratory, renal, or other) that would limit tolerance of infusion or require hospital-level care, provide clinical justification and descriptions.

Clinical section lists these conditional items and requests explanations when applicable (chunk 8).

Continuation-specific documentation: For continuation requests, document whether the patient is experiencing disease stability or improvement while receiving the medication.

Continuation requests require documentation of stability or improvement (chunk 11).

Adverse event history: Document any prior infusion-related adverse events and whether they failed conventional interventions, or any severe adverse events (anaphylaxis, anaphylactoid reactions, myocardial infarction, thromboembolism, seizures) during or immediately after infusion.

Form asks about prior adverse events and response to interventions (chunk 8).

Provider Actions & Submission Requirements

Prior Authorization

Precertification Required

Precertification must be requested prior to outpatient infusion or continuation of therapy. All fields on the precertification form must be completed and legible; incomplete or illegible submissions may prevent review and result in denial or delay. Contact Aetna Precertification Notification: Phone: 1-866-752-7021 (TTY: 711); Fax: 1-888-267-3277. For Medicare Advantage Part B, use the Medicare request form.

Precertification required before outpatient infusion or continuation of therapy
Aetna Precertification Notification: 1-866-752-7021 (TTY: 711); Fax: 1-888-267-3277
Use Medicare request form for Medicare Advantage Part B

Documentation Required

Prior MS Therapy Consideration

The precertification request form requires detailed documentation of prior multiple sclerosis (MS) therapy history. The form asks whether treatment with Tysabri (natalizumab) and Ocrevus (ocrelizumab) was ineffective, not tolerated, or contraindicated. Indicate whether the patient is taking other disease-modifying MS agents and whether the requested medication will be prescribed by or in consultation with a neurologist.

Was treatment with Tysabri and Ocrevus ineffective, not tolerated, or contraindicated? (Yes/No)
Is the patient taking any other disease-modifying MS agent? (Yes/No)
Will the medication be prescribed by or in consultation with a neurologist? (Yes/No)

Documentation Required

Required Documentation

Providers must submit complete demographic, insurance, prescriber, product/dosing, diagnosis, and clinical information as indicated on the precertification form. Required documentation includes patient identifiers, weight/height, allergies, start or continuation dates, prescriber credentials (including NPI and state license), specialty, product name, dose and frequency, primary and secondary ICD codes, and the full clinical questionnaire responses (infusion setting, adverse events, venous access issues, behavioral or medical stability concerns, and continuation therapy status). For patients 17 years or younger, prescriber must attest that benefits outweigh risks.

Patient demographic and contact information (name, DOB, address, phones, email)
Patient weight and height; allergies
Start of treatment date or date of last treatment for continuation requests
Prescriber information: name, degree (MD/DO/NP/PA), address, phone, fax, state license number, NPI, DEA#, specialty, office contact
Product information: Briumvi (ublituximab-xiiy) — dose and frequency
Diagnosis: primary and any secondary ICD-10 codes
Clinical information: outpatient infusion setting, adverse events history, venous access issues, behavioral/physical/cognitive impairments, medical stability (cardiovascular/respiratory/renal/other), other MS therapies, neurologist involvement
For continuation: documentation of disease stability or improvement while on therapy
For patients ≤17 years: prescriber attestation that benefits outweigh risks

Denial Risk

Incomplete Submission Risk

Incomplete or illegible fields on the precertification request may prevent clinical review and can result in denial or delay of the request. Ensure all required sections are filled and legible before submission.

All fields must be completed and legible for precertification review
Incomplete submissions may prevent review and cause denial or delay

Background

Background: Briumvi (ublituximab-xiiy) is a disease-modifying therapy for relapsing forms of multiple sclerosis. This form is Aetna’s precertification request for Briumvi and gathers the clinical and administrative details required to evaluate requests to start or continue treatment, including treatment start/continuation dates, clinical information about MS subtype and prior therapies, infusion site and administration details, and justification when outpatient hospital-level care is requested. Providers must supply all requested clinical details to support a coverage determination.

Definitions

Relapsing forms of multiple sclerosis

Selectable diagnosis optionRelapsing forms of multiple sclerosis — includes relapsing-remitting and secondary progressive disease for those who continue to experience relapse

Form usage noteMust be marked on the precertification form when patient meets relapsing MS subtype criteria

Clinical contextUsed to indicate eligibility for Briumvi (ublituximab-xiiy) consideration as a disease-modifying therapy for relapsing MS

Clinically isolated syndrome

Selectable diagnosis optionClinically isolated syndrome of multiple sclerosis — selectable on the form for early demyelinating events suggestive of MS

Form usage noteMark this category when the patient has a single clinical demyelinating event under evaluation for MS

Clinical contextAllows documentation of early MS presentations when requesting Briumvi precertification

Primary ICD Code	Primary ICD code field for diagnosis
Secondary ICD Code	Secondary ICD code field
Other ICD Code	Additional ICD code field

OpenPayer

Briumvi (ublituximab-xiiy) Medication Precertification Request Form

Coverage & Medical Necessity Criteria

Coding — Diagnosis & Procedure Codes

Provider Actions & Submission Requirements

Background

Definitions