CurrentAetnaPolicy N/A

RYBREVANT (amivantamab-vmjw) Medication Precertification Request

This form governs precertification requests to Aetna for the drug RYBREVANT (amivantamab-vmjw) for members being considered for initiation or continuation of therapy for non-small cell lung cancer (NSCLC). It specifies required patient, prescriber, diagnosis, and clinical information needed for review.

Policy Summary

PayerAetna

PolicyRYBREVANT (amivantamab-vmjw) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification must be requested from Aetna using this form; contact Aetna Precertification Notification at 1-866-752-7021 or fax 1-888-267-3277 for submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1page(s)

mandatoryAll fields must be completed

NSCLCPrimary diagnosis

EGFR ex20Mutation query

Precert phoneContact

Coverage Criteria for RYBREVANT

Policy Summary

PayerAetna

PolicyRYBREVANT (amivantamab-vmjw) Medication Precertification Request

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification must be requested from Aetna using this form; contact Aetna Precertification Notification at 1-866-752-7021 or fax 1-888-267-3277 for submission.

SourceLink

On This Page

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Clinical information required

Precertification requests for RYBREVANT will be evaluated when the following clinical information is provided:

Required clinical items: 1) Diagnosis of non-small cell lung cancer (NSCLC); 2) For initiation: clinical setting (recurrent, advanced, metastatic, other); 3) Presence of EGFR exon 20 insertion mutation; 4) Documentation whether disease progressed on or after platinum-based chemotherapy; 5) Whether drug will be used as a single agent; 6) For continuation: evidence of unacceptable toxicity or disease progression while on current regimen.

Responses to each item are captured as yes/no checkboxes on the form.

Precertification requests for RYBREVANT require explicit confirmation that the patient has a diagnosis of non-small cell lung cancer (NSCLC). The precertification form includes a required checkbox asking “Does the patient have a diagnosis of non-small cell lung cancer (NSCLC)?” and requests completion of this field for all submissions. Requests that do not confirm NSCLC (for example, submissions for other diagnoses) therefore lack the required clinical information for review and may be returned or denied.

Provider Actions and Required Documentation

Prior Authorization

Precertification request — must be requested from Aetna

Precertification requests must be submitted to Aetna using the Rybrevant medication precertification form. All fields must be completed and legible; incomplete or illegible submissions may prevent precertification review. 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.

Start of treatment / Continuation of therapy — include start date and, for continuation, date of last treatment
Precertification Requested By, Phone, Fax — include submitting party contact details

Documentation Required

Prior platinum therapy — document progression status

Indicate whether disease progressed on or after platinum-based chemotherapy (e.g., cisplatin, carboplatin). The form asks: "Has the disease progressed on or after platinum-based chemotherapy?" Mark Yes or No and include supporting clinical documentation (treatment history, dates, and response).

Document prior platinum-based chemotherapy agents and dates (e.g., cisplatin, carboplatin)
If progression occurred, provide clinical notes, imaging or pathology reports that document progression

Documentation Required

Required documentation — patient, prescriber, product, and clinical details

Required documentation must be provided with every precertification request to support clinical review. Include complete patient demographics, prescriber details, product request, and clinical information as specified on the form. All required fields in sections A, C, E and G must be completed.

Patient information: name, DOB, address, contact numbers, weight and height, allergies
Prescriber information: name, license, NPI, specialty, address, phone, fax, office contact
Product information: requested product (RYBREVANT), dose, frequency
Clinical information: diagnosis (NSCLC), EGFR exon 20 insertion mutation status, treatment setting (recurrent/advanced/metastatic/other), prior therapies, evidence of toxicity or progression for continuation requests
Signature and date: request completed by (signature required)

Denial Risk

Incomplete submission risk — complete and legible fields required

All fields on the precertification form must be completed and legible. Omissions or illegible entries may delay or prevent review; Aetna may request additional information or clarification to evaluate requests. Note fraud warning and ensure signature/date are provided.

Fraud warning statement present on form — ensure accuracy of information
Aetna may request additional information if needed

Background

RYBREVANT (amivantamab-vmjw) is a targeted antineoplastic therapy used in patients with non-small cell lung cancer (NSCLC), and this precertification form specifically queries for the presence of an EGFR exon 20 insertion mutation. The form requires documentation of mutation status and, for initiation requests, the clinical setting (recurrent, advanced, metastatic, or other) as well as whether disease progressed on or after platinum-based chemotherapy. For continuation requests the form requires documentation of unacceptable toxicity or disease progression on the current regimen.

Definitions

Initiation vs Continuation

Initiation — required clinical settingIndicate clinical setting: recurrent, advanced, metastatic, or other (checkbox on form)

Initiation — prior therapy statusConfirm whether disease progressed on or after platinum-based chemotherapy (e.g., cisplatin, carboplatin)

Initiation — mutation statusConfirm presence of EGFR exon 20 insertion mutation (Yes/No)

Continuation — on-treatment evidenceDocument evidence of unacceptable toxicity or disease progression while on current regimen (Yes/No)

Common to all requestsConfirm diagnosis of non-small cell lung cancer (NSCLC) (Yes/No)

Initial Therapy Criteria

Initiation therapy requirements

For initiation requests

Initiation documentation: Indicate clinical setting (recurrent, advanced, metastatic, other); confirm EGFR exon 20 insertion mutation status; document whether disease progressed on or after platinum-based chemotherapy; indicate if the requested drug will be used as a single agent; provide requested product, dose, and frequency.

Dose and frequency fields are on the product information section of the form.

Primary ICD Code	Primary diagnosis ICD code for claim
Secondary ICD Code	Secondary diagnosis ICD code
Other ICD Code	Additional ICD codes as applicable

OpenPayer

RYBREVANT (amivantamab-vmjw) Medication Precertification Request

Coverage Criteria for RYBREVANT

Coding (CPT & ICD-10)

Provider Actions and Required Documentation

Background

Definitions

Initial Therapy Criteria

Continuation Therapy Criteria

Step Therapy

Site of Care / Place of Administration