CurrentCignaPolicy V031526

Epcoritamab (Epkinly) prior authorization for B‑cell lymphomas

This document is a Cigna prior authorization form governing requests for Epkinly (epcoritamab) injections for treatment of various B‑cell lymphomas; it applies to providers submitting coverage requests for Cigna members. It specifies required patient, prescriber, clinical, and dispensing information to process the request.

Policy Summary

PayerCigna

PolicyEpcoritamab (Epkinly) prior authorization for B‑cell lymphomas

Policy CodePolicy V031526

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form (fax to (855) 840-1678 or online via CoverMyMeds/SureScripts) with required patient, prescriber, clinical, and dispensing information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 strengthsavailable product presentations listed

7 listeddiagnoses selectable on form

5 business daysstandard response time

faxprimary submission

Coverage Criteria and Requirements

Information required for clinical coverage review

Coverage review requires submission of all of the following provided items and answers as applicable to the diagnosis selected

Required form elements: Completed patient identifiers and prescriber information (all asterisked items), requested medication strength (Epkinly 4 mg or 48 mg), ICD-10 diagnosis code, directions for use, quantity, duration of therapy, and indication whether medication is for a chronic/long-term condition

Supports administrative and clinical review

Dispensing and administrative details: Facility and/or dispensing provider name, address, state, tax ID (or NPI/TIN as indicated), and source of medication (specialty pharmacy, hospital, retail, or physician office)

Required to determine dispensing channel and billing

Attestation and signature: Attestation that information is true and accurate and prescriber signature with date

Policy Summary

PayerCigna

PolicyEpcoritamab (Epkinly) prior authorization for B‑cell lymphomas

Policy CodePolicy V031526

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form (fax to (855) 840-1678 or online via CoverMyMeds/SureScripts) with required patient, prescriber, clinical, and dispensing information.

SourceLink

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Form must be signed to complete request

Diagnosis-specific clinical details

Follicular lymphoma (FL): Indicate whether disease is relapsed or refractory (Yes/No) AND indicate whether Epkinly will be used as single-agent therapy (Yes/No). If not single-agent, indicate whether it will be used in combination with lenalidomide and rituximab (Yes/No)
Regimen context required for FL
DLBCL / high-grade / transformation / HIV-related B-cell lymphoma / PTLD: Indicate whether Epkinly will be the only medication used at this time for this diagnosis (Yes/No). Indicate whether the patient has received any prior systemic therapy for this diagnosis (Yes/No). If yes, state how many different lines of systemic therapy: Only 1 OR 2 or more
Used to assess line of therapy
All other indications: Provide additional pertinent clinical information specific to the diagnosis selected
Reviewer may request supporting records

The form does not list any explicit exclusions for Epkinly (epcoritamab). There is, however, a selectable option for "All other indications or diagnoses" on the request form, which signals that requests for indications not separately enumerated will require submission of additional clinical detail to support coverage review.

The form does not define specific scenarios that are automatically not medically necessary. Instead, determinations about medical necessity are made during clinical review based on the documentation supplied with the request (for example, answers about relapsed/refractory status, prior lines of systemic therapy, and intended regimen).

Form Coding Fields

Form fields for codesmixed

N/A	No CPT/HCPCS/ICD-10/other billing codes are listed on the form; ICD10 is a field to be provided by the requester.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of the requested medication. Fax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts in your EHR. If this is an urgent request, call (800) 882-4462.

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
Urgent requests: call (800) 882-4462

Documentation Required

Therapy Context and Prior Therapy Documentation

Document clinical context for the therapy requested. Indicate whether the medication will be used as single-agent therapy or in combination (for follicular lymphoma, state if single agent; if not, indicate whether it will be used with lenalidomide and rituximab). For DLBCL, high-grade B-cell lymphoma, histologic transformation, HIV-related B-cell lymphoma or PTLD, indicate whether the requested medication will be the only agent used and document prior systemic therapy: whether any systemic therapy was received and how many different lines of systemic therapy were tried (Only 1, or 2 or more). Include duration of therapy, quantity, directions for use, and whether the condition is chronic/long-term.

Specify single-agent vs combination use (if FL: single agent? if no, used with lenalidomide and rituximab?)
For DLBCL/high-grade/histologic transformation/HIV-related B-cell lymphoma/PTLD: confirm if this is the only agent being used and document prior systemic therapy (none / only 1 / 2 or more)
Provide ICD-10, directions for use, quantity, duration of therapy, and whether condition is chronic/long-term

Documentation Required

Required Documentation and Incomplete Form Notice

Complete all required patient and prescriber identifiers and attachments. Due to privacy regulations, Cigna cannot respond via fax with the outcome of the review unless all asterisked (*) items on the form are completed. Incomplete forms may delay or impede the prior authorization response.

Required patient identifiers: Patient name, Cigna ID, Date of Birth, Patient address, Patient phone
Required prescriber/office identifiers: Physician name, Specialty, DEA/NPI or TIN, Office contact person, Office phone, Office fax, Office address
Required clinical attachments/fields: Medication requested (include strength and formulation), ICD-10, directions for use, quantity, duration of therapy, clinical information/attestation, prescriber signature and date
Note: All asterisked (*) items must be completed for a fax response; incomplete forms may impede timely handling

Background

Epcoritamab (Epkinly) is requested on this prior authorization form for use in multiple B‑cell lymphomas, including diffuse large B‑cell lymphoma, follicular lymphoma, high‑grade B‑cell lymphoma, histologic transformation to DLBCL, HIV‑related B‑cell lymphoma, and post‑transplant lymphoproliferative disorder (PTLD). The form captures diagnosis‑specific clinical details — for example, whether follicular lymphoma is relapsed or refractory and whether Epkinly will be used as a single agent or in combination with lenalidomide and rituximab — and requests prior systemic therapy history and line(s) of therapy for DLBCL and related diagnoses to support the coverage review.

Definitions and Selectable Diagnoses

Diagnoses listed

Diffuse large B-cell lymphoma (DLBCL)Selectable indication on the form

Follicular lymphoma (FL)Selectable indication on the form

High grade B-cell lymphomaSelectable indication on the form

Histologic transformation of indolent lymphoma to DLBCLSelectable indication on the form

HIV-related B-cell lymphomaSelectable indication on the form

Post-transplant lymphoproliferative disorder (PTLD)Selectable indication on the form

All other indications or diagnosesSelectable option on the form for diagnoses not listed

Line of Therapy

Line of therapy / prior systemic therapy

Prior systemic therapy: For DLBCL, high-grade B-cell lymphoma, histologic transformation to DLBCL, HIV-related B-cell lymphoma, or PTLD: indicate whether the patient has received any systemic therapy for this diagnosis (Yes/No). If yes, state how many different lines of systemic therapy the patient has tried for this diagnosis (Only 1 OR 2 or more)

Used to assess line of therapy

Regimens and Combinations

Regimen	Form question (FL)	Response options	Coverage status
{"text":"Epkinly as single-agent therapy","status":""},{"text":"Will the requested medication be used as single agent therapy for this condition?","status":""},{"text":"Yes; No","status":""},{"text":"Covered","status":"covered"}
{"text":"Epkinly in combination with lenalidomide and rituximab","status":""},{"text":"If no to single agent: Will the requested medication be used in combination with lenalidomide and rituximab?","status":""},{"text":"Yes; No","status":""},{"text":"Covered","status":"covered"}