CurrentCignaPolicy N/A

prior_authorization_request_form_scenesse

A Cigna prior authorization request form to collect clinical and administrative information for coverage review of Scenesse (afamelanotide) 16 mg implant for erythropoietic protoporphyria (EPP) or other diagnoses; includes patient, prescriber, dispensing, and clinical attestation fields and submission instructions.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_scenesse

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts in EHR, including all asterisked patient items to receive the outcome via fax.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this brief documents a prior authorization request form only.

1Medication covered on form

1Primary listed indication (EPP)

5Required clinical items to document

Policy summary

This is a Cigna prior authorization request form to collect necessary patient, prescriber, dispensing, diagnostic, and clinical information to support a coverage decision for Scenesse (afamelanotide) 16 mg implant, primarily for Erythropoietic Protoporphyria (EPP). The form gathers patient identifiers and contact details, prescriber and office information, medication directions (dose, quantity, duration), where the medication will be obtained, facility/dispensing site details, diagnosis selection, required clinical test results and history (including free erythrocyte protoporphyrin lab results, molecular genetic testing if applicable, and documented porphyric phototoxic reaction), specialty prescribing/consultation confirmation, additional pertinent clinical information, and prescriber attestation and signature to support authorization review.

Information requested on the prior authorization form

Information requested for authorization review

Form requests the following clinical and administrative items to support a coverage determination:

ALL of the following

Patient identifiers
- Patient Name
- Cigna ID
- Date of Birth
- Patient Street Address
- Patient Phone
Physician identifiers
- Physician Name
- Specialty
- DEA, NPI or TIN
- Office Contact Person
- Office Phone
- Office Fax
- Office Street Address
Medication requested
- Scenesse 16mg Implant
- Directions for use
- Dose
- Quantity
- Duration of therapy
- ICD10 diagnosis code
Where medication obtained
- Prescriber's office stock (billing on a medical claim form)
- Other (specify)
Facility/doctor dispensing/administering medication
- Facility Name
- State
- Tax ID
- Address (City, State, Zip)
Diagnosis selection
- Erythropoietic Protoporphyria (including X-Linked Protoporphyria)
- Other (please specify)
Clinical test and history items
- Has patient had a lab test showing a free erythrocyte protoporphyrin level above the normal reference range for the reporting laboratory? (Yes/No)
- If no or unknown: has patient had a molecular genetic test showing results consistent with the diagnosis? (Yes/No)
- Does patient have a documented history of at least one porphyric phototoxic reaction? (Yes/No)
- Is Scenesse being prescribed by, or in consultation with, a Dermatologist, Gastroenterologist, Hepatologist, Medical Geneticist, or physician specializing in cutaneous porphyrias? (Yes/No)
Additional pertinent clinical information: Please provide additional pertinent clinical information, including disease stage, prior therapy, performance status, current use/dates and how previously obtained (samples/out-of-pocket)
Prescriber attestation and signature with date

What providers must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via covermymeds.com or SureScripts in your EHR. Include all asterisked patient items so the outcome can be returned via fax.

Fax: (855) 840-1678
Online: www.covermymeds.com or SureScripts in EHR

Prior Authorization

Urgent request procedure

If the request is urgent, call (800) 882-4462 to expedite the review. Our standard response time for prescription drug coverage requests is 5 business days.

Phone: (800) 882-4462
Standard response time: 5 business days

Documentation Required

Clinical documentation required

Provide the requested clinical documentation for review: laboratory and genetic test results, history of phototoxic reaction, specialty consult details, and prior/current therapy information.

Free erythrocyte protoporphyrin results
Molecular genetic test results (if applicable)
Documented history of porphyric phototoxic reaction
Specialty consult information (Dermatologist, Gastroenterologist, Hepatologist, Medical Geneticist, or physician specializing in cutaneous porphyrias)
Prior and current therapy details (dates, how obtained: samples/out-of-pocket, dosing)

Billing Rule

Distribution channel note

Indicate where the medication will be obtained and note that Scenesse is direct distribution to trained/accredited EPP Centers. If obtained from the prescriber's office stock, billing is on a medical claim form; specify the source on the form.

Office stock = billed on a medical claim form
Indicate source (prescriber's office stock or other) on the form

Background and definitions

This form’s purpose and scope are to obtain the clinical and administrative data Cigna needs to review and determine coverage for Scenesse (afamelanotide) 16 mg implant — including patient and prescriber identifiers, medication request details, where the medication will be sourced (for example prescriber’s office stock or other), facility/dispensing information, diagnosis (EPP or other), and supporting clinical documentation such as lab results, genetic testing, history of porphyric phototoxic reaction, specialty consultation, and prescriber attestation; completed forms may be faxed or submitted online and urgent requests can be called in for expedited review.