CurrentCignaPolicy N/A

beleodaq_prior_authorization_form

A Cigna prior authorization request form to collect patient, prescriber, diagnosis, and clinical information for medical benefit requests of Beleodaq (belinostat) 500 mg vial, including site of care, infusion setting, and disease-specific questions for T-cell lymphomas.

Policy Summary

PayerCigna

Policybeleodaq_prior_authorization_form

Policy CodePolicy N/A

Change TypeInformational prior authorization form

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts and complete all asterisked items to receive a faxed response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is a prior authorization request form to collect information for evaluation.

1Form for single drug

10Diagnoses listed

5Conditional clinical questions

Beleodaq (belinostat) prior authorization form — summary

This Cigna prior authorization request form is used to collect required patient and prescriber identification and clinical information to evaluate coverage for Beleodaq 500 mg vial. The form gathers key identifiers (physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, and contact/address fields) and requires completion of all asterisked items for Cigna to respond via fax.

The form collects clinical details needed to assess therapy for T‑cell lymphomas and related diagnoses, including the requested medication (Beleodaq 500mg vial), ICD‑10 code, dose, frequency, duration, patient height/weight, diagnosis selection (e.g., ATLL, AITL, cALCL, EATL/ETTL, extranodal NK/T‑cell lymphoma [nasal type], HSGDTCL, MF/SS, PTCL, sALCL, Other), and disease‑specific yes/no questions about relapsed/refractory status and single‑agent use. Additional information requested includes disease stage, prior therapies, performance status, and names/doses/schedule of concurrent agents.

Form fields and conditional clinical questions

The form requests completion of all asterisked fields and specific clinical yes/no questions depending on diagnosis.

ALL of the following

Required asterisked patient and prescriber identification fields: All asterisked patient and prescriber identification fields must be completed for Cigna to respond via fax
Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address are asterisked.
Medication requested: Beleodaq 500mg vial requested
Brand name for belinostat, an oncology medication; the form requests Beleodaq 500 mg vial.
Site of acquisition
- Prescriber's office stock (billing on a medical claim form)
- Home Health / Home Infusion vendor
- Other (specify)
Site of administration availability
- Is the patient a candidate for home infusion? (Yes/No)
- Does the physician have an in-office infusion site? (Yes/No)
Chronic/Long-term indicator: Indicate whether medication is for a chronic/long-term condition (Yes/No)
Diagnosis selection: Select diagnosis related to use from provided list
List: ATLL; AITL; cALCL; EATL/ETTL; extranodal NK/T-cell lymphoma (nasal type); HSGDTCL; MF/SS; PTCL; sALCL; Other
Diagnosis-specific clinical questions
- Relapsed or refractory for certain diagnoses: If diagnosis is ATLL, AITL, cALCL, extranodal NK/T-cell lymphoma (nasal type), or PTCL: Does your patient have relapsed or refractory disease? (Yes/No)
- Refractory for HSGDTCL: If diagnosis is HSGDTCL: Does your patient have refractory disease? (Yes/No)
- Single-agent therapy question: If diagnosis is ATLL, cALCL, extranodal NK/T-cell lymphoma (nasal type), or HSGDTCL: Will Beleodaq be used as single agent therapy? (Yes/No)
Additional information requested: Provide additional information including disease stage, prior therapy, performance status, and names/doses/schedule of concurrent agents

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Required provider actions and documentation

Prior Authorization

Submit completed prior authorization form

Fax completed form to the number below or submit the completed prior authorization form online. Complete all asterisked (*) items to receive a faxed response.

Fax: (855) 840-1678
Online: CoverMyMeds or SureScripts

Prior Authorization

Urgent request handling

For urgent requests, call the phone number below to expedite handling. 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

Select the diagnosis and answer the applicable disease-specific questions about relapsed/refractory status and single-agent therapy. Provide additional clinical details including disease stage, prior therapy, performance status, and names/doses/schedule of concurrent agents.

Billing Rule

Site of acquisition specification

Indicate where the medication will be obtained by selecting prescriber’s office stock, home infusion/vendor, or other. Note that selecting prescriber's office stock indicates billing on a medical claim form.

Prescriber's office stock = billing on a medical claim form
Home Health / Home Infusion vendor
Other (specify)

Documentation Required

Attestation and audit

Prescriber must sign attestation that the information provided is true and accurate and acknowledges the health plan or its designees may perform a routine audit and request medical information to verify accuracy.

OpenPayer

beleodaq_prior_authorization_form

Beleodaq (belinostat) prior authorization form — summary

Form fields and conditional clinical questions

Billing / procedure codes

Required provider actions and documentation

Definitions

Document revision history