CurrentCignaPolicy v060120

Beleodaq (belinostat) prior authorization form

This document is a Cigna prior authorization request form for Beleodaq (belinostat) used to request coverage for specified T-cell lymphoma indications and to collect required clinical and administrative information from providers and patients.

Policy Summary

PayerCigna

PolicyBeleodaq (belinostat) prior authorization form

Policy CodePolicy v060120

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit the completed prior authorization form by fax to (855) 840-1678 or via CoverMyMeds/SureScripts for standard review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11listed diagnosis options

5dstandard response time

1fax number

Coverage Criteria

Form-required clinical criteria for coverage review

Coverage consideration will be based on documentation of ALL applicable items selected and provided on the form

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The prior authorization form requires completion of all items marked with an asterisk (*) for the review to proceed as submitted. In particular, the form warns that responses cannot be returned via fax unless all asterisked patient and provider items are completed, which may prevent a timely faxed outcome when required fields are missing. Providers should ensure every required field is completed on the form before submission to avoid delays or inability to receive faxed responses.

The form itself does not include explicit statements listing conditions considered not medically necessary. It is structured to collect required administrative and clinical data but does not specify any on-form exclusions or ‘‘not medically necessary’‘ language that would preclude coverage; medical necessity determinations will be made by the reviewer using the clinical information supplied.

Coding and Codes

Requested medicationmixed

Beleodaq 500mg vial

Medication requested option listed on form (not an NDC or HCPCS in the form)

Diagnosis code fieldICD-10

ICD10

Field for diagnosis code(s) supporting use

Response time for standard review

Standard review timeframe5 business days (standard response time for prescription drug coverage requests)

Urgent review optionForm includes an 'Urgent' checkbox; selecting it attests that applying the standard review timeframe may seriously jeopardize life, health, or function—call the urgent number for expedited review

Submission methodsSubmit completed prior authorization form by fax to (855) 840-1678 or via CoverMyMeds/SureScripts

Provider Actions and Submission Requirements

Prior Authorization

Submission and Turnaround

Fax the completed prior authorization form to (855) 840-1678. For URGENT requests, call (800) 882-4462 (800.88.CIGNA). Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, call to expedite the review. You can also submit online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Fax: (855) 840-1678
Urgent phone: (800) 882-4462
Standard review timeframe: 5 business days
Online submission: www.covermymeds.com/main/prior-authorization-forms/cigna/

Note

Clinical Pathway Information

Complete all required clinical fields on the form. The form asks specifically whether the patient has relapsed or refractory disease for specified histologies, and whether Beleodaq will be used as single-agent therapy for certain diagnoses. Include disease-specific answers and details on prior therapies, disease stage, performance status, and concurrent agents (names, doses, and administration schedule).

If ATLL, AITL, cALCL, extranodal NK/T-cell lymphoma (nasal type), or PTCL: indicate relapsed or refractory status (Yes/No).
If HSTL (HSGDTCL): indicate refractory status (Yes/No).
If ATLL, cALCL, extranodal NK/T-cell lymphoma (nasal type), or HSTL: indicate if Beleodaq will be used as single-agent therapy (Yes/No).
Provide additional information: disease stage, prior therapy, performance status, and names/doses/admin schedule of concurrent agents.

Documentation Required

Required Documentation

All asterisked (*) items on the form must be completed. Provide patient demographics, Cigna ID, date of birth, medication requested (Beleodaq 500mg vial), ICD-10 diagnosis, dose, frequency and duration of therapy, patient height/weight, facility/dispensing provider details, and prescriber identification (DEA, NPI or TIN). Attach supporting documentation for prior therapies and clinical status as available.

Required patient demographics: Patient name, Cigna ID, Date of Birth, Address, Phone
Required prescriber info: Physician name, Specialty, DEA/NPI/TIN, Office contact, Office phone/fax/address
Medication details: Beleodaq formulation requested, ICD-10 diagnosis, dose, frequency, duration
Clinical/supporting documentation: prior therapies (agents, doses, dates), disease stage, performance status
Facility/dispensing information: facility name, tax ID, address

Denial Risk

Incomplete Form Risk

Incomplete forms or missing asterisked items may prevent fax response or delay processing. If required fields are not completed, the review may be postponed pending receipt of complete information.

All asterisked (*) fields must be completed for a fax response.
Missing clinical details or prior therapy information may delay or prevent authorization.

Covered Regimens

Regimen	Indication / clinical requirement	Coverage status
Belinostat monotherapy (Beleodaq)	Use as single‑agent therapy for specified T‑cell lymphoma subtypes when clinical documentation indicates intent for single‑agent use (form queries single‑agent use for ATLL, cALCL, extranodal NK/T‑cell lymphoma [nasal type], and HSGDTCL). Additional required clinical information: disease stage, prior therapy, performance status, and names/doses/schedules of concurrent agents.	Covered with criteria

Definitions

Definition / capture of relapsed or refractory disease status

Relapsed or refractory — primary captureForm asks: 'Does your patient have relapsed or refractory disease?' with Yes/No responses for ATLL, AITL, cALCL, extranodal NK/T-cell lymphoma (nasal type), and PTCL.

HSGDTCL — refractory captureFor hepatosplenic gamma-delta T-cell lymphoma (HSGDTCL) the form specifically asks whether the patient has refractory disease (Yes/No).

Single-agent use questionFor ATLL, cALCL, extranodal NK/T-cell lymphoma (nasal type), and HSGDTCL the form asks whether Beleodaq will be used as single-agent therapy (Yes/No), which informs review of relapsed/refractory status in context.

Context — required additional detailsThe form requests additional clinical information (disease stage, prior therapy, performance status, concurrent agents) to support the relapsed/refractory designation.

Background

This prior authorization form is specific to Beleodaq (belinostat) and is intended to collect the administrative and clinical information necessary to evaluate requests for belinostat use in T‑cell lymphoma subtypes. The form lists multiple diagnosis options for T‑cell lymphomas and requests disease status (for example, whether the disease is relapsed or refractory where applicable), prior therapies, performance status, and intent to use belinostat as single‑agent therapy for specified indications. The information collected supports the reviewer’s assessment of medical necessity and appropriate line of therapy for belinostat treatment.