CurrentCignaPolicy N/A

Avastin_Alymsys_Prior_Authorization_Form

A Cigna prior authorization request form for bevacizumab products (Avastin, Alymsys) to collect patient, provider, diagnosis, clinical and infusion setting information to support coverage review and decision-making.

Policy Summary

PayerCigna

PolicyAvastin_Alymsys_Prior_Authorization_Form

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionProviders must complete the form including all required asterisked fields, clinical indication-specific questions, prior treatment history with listed alternatives, facility/dispense location, and prescriber attestation/signature to initiate Cigna review.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is a prior authorization request form template with no substantive policy changes.

MultitudeCovered Indications Listed on Form

2Primary branded/specified products

2Listed biosimilar alternatives

Form purpose and scope

This is a Cigna prior authorization request form to collect required patient, prescriber, diagnosis, clinical, prior-therapy, and infusion/dispensing information to review coverage for bevacizumab products (Avastin and Alymsys). The form requires completion of all asterisked patient and prescriber items, documents whether the request is a new start (with dose, frequency, duration), lists the medication requested (Avastin or Alymsys), captures patient weight and ICD-10 diagnosis, and includes extensive indication-specific conditional clinical questions to document medical necessity and prior therapies (including staging, performance status, combination regimens, and prior use of alternative bevacizumab products).

Form completion and submission criteria

Information to be provided by the prescriber to allow Cigna to review the prior authorization request:

Complete required patient and prescriber items: Complete all asterisked (*) patient and prescriber items (physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, patient street address).
Cigna will not respond via fax unless all asterisked items are completed.
Medication requested: Indicate medication requested: Avastin or Alymsys.
Start and dosing information: State whether this is a new start and provide start date, dose, frequency, and duration of therapy.
Concurrent therapy: Specify concurrent agents if medication will be given concurrently with other agents.
Patient weight and diagnosis codes: Provide patient weight and ICD-10 diagnosis code(s).
Select diagnosis: Select specific diagnosis from provided list (extensive oncology and related indications provided on form).
Answer indication-specific questions: For indication-specific questions, answer conditional items (e.g., NSCLC subtype, unresectable/metastatic status, combination regimens, prior therapies, staging, performance status) as applicable.
Document prior bevacizumab alternatives: Document previous use or trial of alternative bevacizumab products (Mvasi, Zirabev) including reasons (not tried, ineffective, adverse reaction, other) and provide supporting details for adverse reactions if claimed.
For alternatives tried, include medication name/strength, dates taken, duration, results, intolerances or adverse reactions; if allergic, indicate whether reaction was due to formulation difference in inactive ingredients and provide details.
Facility/infusion and acquisition details: Provide facility/infusion site details and indicate where medication will be obtained (Accredo Specialty Pharmacy, prescriber's office stock/billing on medical claim, retail pharmacy, home health/home infusion vendor, other).
Infusion may need to occur in lowest cost medically appropriate setting per some Cigna plans. Cigna's nationally preferred specialty pharmacy is Accredo.
Attestation and signature: Attest to accuracy and sign/date the form.
If urgent review requested, prescriber must check 'Urgent' and attest that applying standard review timeframe may seriously jeopardize patient's life, health, or ability to regain maximum function, and call to expedite.

Required provider actions and documentation

Prior Authorization

Complete and submit prior authorization form

Providers must complete the form including all required asterisked fields, clinical indication-specific questions, prior treatment history with listed alternatives, facility/dispense location, and prescriber attestation/signature to initiate Cigna review. Note: asterisked (*) fields are required.

Documentation Required

Document prior trials of alternative bevacizumab products

Include medication name, strength, dates taken, duration, results, intolerances or adverse reactions; if allergic to alternatives, provide documentation if reaction due to formulation differences in inactive ingredients.

Medication name
Strength
Date(s) taken
Duration
Documented results
Intolerances or adverse reactions
Documentation if reaction due to formulation differences in inactive ingredients

Billing Rule

Specify acquisition/administration setting

Indicate where medication will be obtained and provide facility/infusion site details; note some Cigna plans require infusion in the lowest cost medically appropriate setting.

Accredo Specialty Pharmacy (preferred)
Prescriber's office stock (billing on a medical claim)
Retail pharmacy
Home Health / Home Infusion vendor
Facility/infusion site details (name, address, Tax ID)
Note: infusion may need to occur in the lowest-cost medically appropriate setting per some Cigna plans

Prior Authorization

Urgent request attestation

If requesting urgent review, prescriber must check 'Urgent' and attest that applying the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function; and call to expedite.

Check the 'Urgent' box and call to expedite the request

Documentation Required

Answer indication-specific clinical questions

Provide responses to numerous conditional clinical questions (e.g., staging, prior systemic therapies, combination regimens, performance status, HRD status) as applicable to support medical necessity determination.

Examples: staging
Prior systemic therapies
Combination regimens
Performance status
HRD status

Background and definitions

This Cigna prior authorization form is intended to gather the clinical, administrative, and dispensing information necessary to review coverage requests for bevacizumab products (Avastin and Alymsys). It contains extensive indication-specific conditional questions to document medical necessity and prior therapies across a wide range of oncology and related diagnoses (for example NSCLC, CRC, ovarian, RCC, HCC, CNS tumors, and others), and requires documentation of prior trials of listed alternatives and detailed clinical information as applicable. The form also identifies Accredo as Cigna's nationally preferred specialty pharmacy for dispensing the medication.

Accredo Specialty Pharmacy: Cigna's nationally preferred specialty pharmacy (contact and NCPDP provided on the form: Accredo, 1620 Century Center Pkwy, Memphis, TN 38134-8822 | NCPDP 4436920; Fax 888.302.1028; Verbal 866.759.1557).