CurrentAetnaPolicy N/A

Opdualag Medication Precertification Request

Aetna precertification request form to collect patient, prescriber, dispensing, diagnosis, and clinical information required for prior authorization of Opdualag (nivolumab and relatlimab-rmbw) therapy, including start or continuation details and clinical justification for infusion setting.

Policy Summary

PayerAetna

PolicyOpdualag Medication Precertification Request

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and submit this precertification request form with all required clinical documentation for Opdualag prior to treatment initiation or for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — form remains an informational precertification request to collect required documentation.

1Primary Indication listed

MultipleRequired documentation categories

Opdualag precertification request — at a glance

Scope: This is an Aetna precertification/authorization request form to collect patient, prescriber, dispensing, product, diagnosis, and detailed clinical information required for prior authorization of Opdualag (nivolumab and relatlimab-rmbw) infusion therapy, including start or continuation details and clinical justification for the infusion setting. Background/Status: The form is current and must be completed and submitted with all required clinical documentation prior to treatment initiation or for continuation requests; Aetna may request additional information and may deny or delay coverage if required information is not provided. Subject: Opdualag (nivolumab and relatlimab-rmbw) precertification request form. Definitions: Opdualag — Brand name for combination nivolumab and relatlimab-rmbw. Use: This Aetna form is used to collect administrative, prescriber, dispensing, diagnosis, and clinical information to support approval decisions for infusion therapy.

Opdualag Precertification Snapshot

PayerAetna

PolicyOpdualag Medication Precertification Request

Policy NumberN/A

StatusCURRENT

Scope SummaryAetna precertification request form to collect patient, prescriber, dispensing, diagnosis, and clinical information required for prior authorization of Opdualag (nivolumab and relatlimab-rmbw) therapy, including start or continuation details and clinical justification for infusion setting.

NoteForm used for initiation and continuation requests; Medicare Advantage Part B members must use Medicare form (see Provider Actions)

Required clinical information for precertification

Required Clinical Information for Precertification

Form fields to be completed for all precertification requests and continuation requests; must provide clinical documentation.

ALL of the following

Indication: Melanoma (checkbox)
Clinical setting (select one or more)
- Unresectable disease
- Metastatic disease
- Other
Continuation request — disease progression/toxicity: For continuation requests: specify if there is evidence of disease progression or unacceptable toxicity while on current regimen (Yes/No)
Continuation request — outpatient hospital setting: For continuation requests: indicate if infusion request is in an outpatient hospital setting (Yes checkbox)
Continuation request — maintenance regimen: For continuation requests: indicate if patient is continuing on a maintenance regimen that includes provider administered combination chemotherapy and specify regimen (Yes/No)
Severe toxicity requiring continuous monitoring: Document severe toxicity requiring continuous monitoring (examples listed) (Yes/No) and explanation if Yes
Adverse events unresponsive or severe infusion reactions: Document adverse events with requested product unresponsive to conventional interventions or severe infusion reactions (Yes/No) and explanation if Yes
Severe venous access issues: Document severe venous access issues requiring special interventions available only in outpatient hospital setting (Yes/No) and explanation if Yes
Behavioral/caregiver limitations: Document significant behavioral issues and/or physical or cognitive impairment that impact infusion safety AND lack of caregiver (Yes/No) and explanation if Yes
Medical instability: Document if patient is medically unstable (respiratory, cardiovascular, renal conditions) limiting tolerance of large volume/load or predispose to severe adverse event that cannot be managed in alternate setting (Yes/No) and provide description
Treatment duration: Indicate if patient is within initial 6 months of starting therapy (Yes/No) and number of continuous months of treatment

What providers must do

Prior Authorization

Precertification submission required

Providers must complete and submit this precertification request form with all required clinical documentation for Opdualag prior to treatment initiation or for continuation requests.

Documentation Required

Clinical documentation required

Providers must document indication (melanoma), clinical setting (unresectable/metastatic/other), toxicities, adverse events, venous access issues, behavioral/caregiver limitations, medical instability, and duration on therapy as applicable.

Indication
Clinical setting
Toxicities
Adverse events
Venous access issues
Behavioral/caregiver limitations
Medical instability
Duration on therapy

Billing Rule

Use Medicare form for Medicare Advantage Part B

For Medicare Advantage Part B members, providers must use the Medicare request form instead of this form.

Denial Risk

Incomplete forms may delay or prevent approval

All fields must be completed and legible; Aetna may request additional information and may deny or delay coverage if required information is not provided.

Background and definitions

This two-page Aetna medication precertification request form is used to collect administrative, insurance, prescriber, dispensing, product, diagnosis, and detailed clinical information to support approval decisions for Opdualag (nivolumab and relatlimab-rmbw) infusion therapy. Special considerations: the form captures outpatient hospital administration needs (questions about whether the infusion request is in an outpatient hospital setting, severe toxicity requiring continuous monitoring, severe venous access issues requiring interventions only available in an outpatient hospital, medical instability, and caregiver/behavioral limitations) to document when outpatient hospital resources are required.

Opdualag — Brand name for combination nivolumab and relatlimab-rmbw.

Policy Summary

PayerAetna

PolicyOpdualag Medication Precertification Request

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete and submit this precertification request form with all required clinical documentation for Opdualag prior to treatment initiation or for continuation requests.

SourceLink

On This Page

Primary ICD Code	Placeholder field for primary diagnosis ICD code (melanoma or other)
Secondary ICD Code	Placeholder field for secondary diagnosis ICD code
Other ICD Code	Placeholder field for other applicable ICD codes

OpenPayer

Opdualag Medication Precertification Request

Opdualag precertification request — at a glance

Required clinical information for precertification

Codes and billing fields on the form

What providers must do

Background and definitions

Document revision history