CurrentAetnaPolicy N/A

Medication Precertification Request

This two-page Aetna precertification request form collects patient, prescriber, administration, product, diagnosis, and clinical justification information required to request prior authorization for Rituxan Hycela (rituximab and hyaluronidase-human) for initiation or continuation of therapy.

Policy Summary

PayerAetna

PolicyMedication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionSubmit the completed precertification request form with all required sections and clinical documentation; all fields must be completed and legible for precertification review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Precertification form pages

MultipleRequired clinical confirmations

What this form is and when to use it

This is Aetna’s one-page (two-page form overall) precertification request form used to obtain prior authorization for Rituxan Hycela (rituximab and hyaluronidase-human). The form collects patient identifiers and contact information, demographic details (including weight and height), insurance/member IDs, prescriber details and credentials, and dispensing provider/administration information (place of administration, administration CPT codes, dispensing provider selection). It also captures product details (requested product, dose, frequency), diagnosis codes (primary and secondary ICD-10 codes), and the clinical justification needed for initiation or continuation of therapy.

This administrative form supplements the medical policy coverage criteria by requiring completion of specific clinical confirmations and documentation (e.g., indication/diagnosis, prior rituximab exposure and IV dosing history, adverse event details, CD20 testing where applicable) as part of the precertification review and authorization process.

Required clinical information for all requests

All requests must include the following completed clinical documentation:

ALL of the following

Has the patient failed treatment with Truxima due to a documented intolerable adverse event (e.g., rash, nausea, vomiting)?
Was the adverse event unexpected and not attributed to the active ingredient as described in the prescribing information (i.e., known adverse reaction for both the brand and biosimilar medication)?
Documented diagnosis - ONE of
- Castleman's disease (CD)
- Chronic lymphocytic leukemia (CLL)
- Diffuse large B-cell lymphoma (DLBCL)
- Follicular lymphoma (FL)
- Gastric mucosa-associated lymphoid tissue (MALT) lymphoma
- Hairy cell leukemia
- High-grade B-cell lymphoma
- Histologic transformation of indolent lymphomas to diffuse large B-cell lymphoma
- Mantle cell lymphoma
- Nodal marginal zone lymphoma
- Nongastric MALT lymphoma
- Post-transplant lymphoproliferative disorder (PTLD)
- Primary cutaneous B-cell lymphoma (e.g., cutaneous marginal zone lymphoma or cutaneous follicle center lymphomas)
- Small lymphocytic lymphoma (SLL)
- Splenic marginal zone lymphoma

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Initiation requests — specific requirements

Initiation requests specific requirements

For initiation of Rituxan Hycela, provide all applicable documentation:

ALL of the following

Does the patient have CD20 positive disease that was confirmed by testing or analysis?
Has the patient received at least one full dose of a rituximab product by IV infusion without experiencing severe adverse reactions?

Continuation requests — specific requirements

Continuation requests specific requirements

For continuation of therapy, provide documentation:

ALL of the following

Document date of last treatment (for continuation requests).
Document whether there is evidence of unacceptable toxicity while on the current regimen.

What the provider must do

Prior Authorization

Precertification required for Rituxan Hycela

Submit the completed precertification request form with all required sections and clinical documentation. All fields must be completed and legible for precertification review. For Medicare Advantage Part B members, use the Medicare Request Form.

Documentation Required

Clinical documentation requirements

Include documentation of prior rituximab exposure (IV dosing and reaction history), provide CD20 testing/results for initiation requests, and document any intolerable adverse events or unacceptable toxicity as applicable.

Billing Rule

Provide administration and dispensing details

Indicate place of administration, select dispensing provider/pharmacy, provide product dose and frequency, and list administration code(s) (CPT) on the form as part of the request.

Denial Risk

Incomplete form risk

Incomplete or illegible fields may result in the request being denied or returned for additional information. The plan may request additional information or clarification to evaluate requests.

Form details and operational notes

This payer-specific Aetna precertification request form is used to collect the clinical and administrative details needed to authorize Rituxan Hycela. It is structured to capture the patient’s documented indication from a listed set of hematologic and lymphoid malignancy diagnoses, the product request (dose and frequency), and administrative details such as place of administration and CPT administration code(s).

The form supplements medical policy by specifically asking whether the patient failed prior rituximab (Truxima) due to a documented intolerable adverse event, whether such an adverse event was unexpected and not attributable to the active ingredient, and by requesting prior rituximab exposure history (IV dosing and reaction history) and CD20 testing confirmation for initiation requests. It also requires documentation of unacceptable toxicity for continuation requests.

Operational stats

Precertification form pages1 (form spans Page 1 of 2; described as two-page form)

Required clinical confirmationsMultiple (e.g., failure with Truxima, CD20 status, prior IV rituximab exposure, toxicity evidence)

Operational noteAll fields must be completed and legible; uses separate Medicare request form for Medicare Advantage Part B

Form sectionsPatient, Insurance, Prescriber, Dispensing/Administration, Product, Diagnosis, Clinical information, Acknowledgement

Policy Summary

PayerAetna

PolicyMedication Precertification Request

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionSubmit the completed precertification request form with all required sections and clinical documentation; all fields must be completed and legible for precertification review.

SourceLink

On This Page

OpenPayer

Medication Precertification Request

What this form is and when to use it

Required clinical information for all requests

Initiation requests — specific requirements

Continuation requests — specific requirements

Codes to include on the request

What the provider must do

Form details and operational notes

Document changes and review dates