CurrentCignaPolicy V041525

Columvi (glofitamab) prior authorization form and coverage criteria

Prior authorization form and instructions for requesting Columvi (glofitamab) for patients with specified B‑cell lymphomas; intended for prescribers and facilities submitting requests to Cigna.

Policy Summary

PayerCigna

PolicyColumvi (glofitamab) prior authorization form and coverage criteria

Policy CodePolicy V041525

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax the fully completed prior authorization form with required clinical and administrative information to (855) 840-1678 for Columvi review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

800.882.4462phone for urgent requests

Accredonationally preferred specialty pharmacy

V041525internal form identifier

Coverage criteria and form-level considerations

Form completion and clinical information required for review

Authorization requests for Columvi will be considered when the request form is fully completed with clinical and administrative information.

Form completion and submission: All required asterisked patient and prescriber identifiers and form fields (physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, patient and office contact info, addresses) and medication request details are completed and submitted.

Fax to (855) 840-1678 or submit online at covermymeds.com or via SureScripts in the EHR; incomplete asterisked fields will prevent Cigna from responding via fax.

Medication and administrative details: Medication requested section must indicate product and formulation (Columvi 10 mg/10 mL or Columvi 2.5 mg/2.5 mL), ICD-10 diagnosis code, directions for use, quantity, duration of therapy, and whether the medication is for a chronic/long-term condition.

Provide dispensing source (e.g., Accredo specialty pharmacy, hospital outpatient, retail, other) and facility/doctor dispensing information as applicable.

Policy Summary

PayerCigna

PolicyColumvi (glofitamab) prior authorization form and coverage criteria

Policy CodePolicy V041525

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax the fully completed prior authorization form with required clinical and administrative information to (855) 840-1678 for Columvi review.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

What the provider must do (submission, documentation, sites)

Prior Authorization

Prior Authorization Required for Columvi

Prior authorization is required for Columvi. Fax requests to (855) 840-1678 and include diagnosis and medication details (drug name, strength, quantity, directions, duration).

Fax number: (855) 840-1678
Include: diagnosis, medication name (Columvi), strength, quantity, directions, duration of therapy

Documentation Required

Prior Therapy Documentation

Document prior systemic therapy for the current diagnosis. For relapsed or refractory DLBCL, indicate whether disease is relapsed or refractory and list the number of prior systemic therapy lines tried.

If DLBCL, indicate: relapsed or refractory (Yes/No)
Document prior systemic therapies and specify number of different lines tried (Only 1; 2 or more)
Provide names, doses, administration schedules, and dates of prior agents

Documentation Required

Facility and Infusion Site Information

Submit facility and infusion site information on the form. Provide dispensing facility/doctor details and indicate home infusion candidacy and whether the physician has an in‑office infusion site.

Facility Name, Tax ID#, Address (City, State, Zip Code), State
Is the patient a candidate for home infusion? (Yes/No)
Does the physician have an in‑office infusion site? (Yes/No)
Indicate where medication will be obtained (Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, Physician's office stock, Other)

Prior Authorization

Required Documentation and Submission Details

Submit a completed prior authorization form including all required physician and patient identifiers and medication request details. Missing asterisked fields will prevent Cigna from responding via fax with the outcome.

Complete all asterisked patient and physician fields (Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address)
Medication requested: select Columvi vial size (10 mg/10 mL or 2.5 mg/2.5 mL), provide ICD-10, directions for use, quantity, and duration
Include additional pertinent clinical information (disease stage, prior therapy, performance status, concurrent agents)
Save time: submit online at covermymeds.com or via SureScripts in EHR

Predefined diagnoses and disease-state fields

Diagnoses listed

Diffuse large B-cell lymphoma (DLBCL, NOS)Predefined checkbox option on the form for diagnosis selection.

High-Grade B-Cell LymphomasPredefined checkbox option on the form for diagnosis selection.

Histologic Transformation to DLBCLPredefined checkbox option listed as 'Histologic Transformation of Indolent Lymphomas to Diffuse Large B-Cell Lymphoma'.

HIV-Related B-Cell LymphomasPredefined checkbox option on the form for diagnosis selection.

Large B-cell lymphoma arising from follicular lymphoma (LBCL from FL)Predefined checkbox option on the form for diagnosis selection.

Mantle Cell LymphomaPredefined checkbox option on the form for diagnosis selection.

Post-Transplant Lymphoproliferative DisordersPredefined checkbox option on the form for diagnosis selection.

Relapsed or refractory DLBCL

Relapsed or refractory DLBCLForm asks: 'Does your patient have relapsed or refractory disease?' with Yes/No checkboxes.

Prior systemic therapy receivedForm asks: 'Has this patient already received any systemic therapy for this diagnosis' with Yes/No checkboxes.

Number of different lines of systemic therapyIf yes, the form asks how many lines: 'Only 1' or '2 or more'.

Additional pertinent clinical informationForm requests disease stage, prior therapy details, performance status, and names/doses/schedules of concurrent agents.

Columvi 10 mg/10 mL	Columvi 10 mg/10 mL vial for injection
Columvi 2.5 mg/2.5 mL	Columvi 2.5 mg/2.5 mL vial for injection
ICD10	Placeholder for diagnosis code(s) to be provided

OpenPayer

Columvi (glofitamab) prior authorization form and coverage criteria

Coverage criteria and form-level considerations

Medication and diagnosis coding entries

What the provider must do (submission, documentation, sites)

Policy background and intent

Predefined diagnoses and disease-state fields

Line-of-therapy criteria