CurrentCignaPolicy N/A

prior_authorization_request_form_epkinly

This document is a Cigna prior authorization request form to be used by providers to request coverage/authorization for Epkinly (epcoritamab) injections, capture patient, prescribing, clinical, and dispensing information, and route the request to Cigna Pharmacy Services or Accredo specialty pharmacy.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_epkinly

Policy CodePolicy N/A

Change TypeAdministrative form (no material changes)

Effective Date

Next Review Date

Key ActionComplete all asterisked patient and physician items on the form and fax to (855) 840-1678; if urgent, also call (800) 882-4462 to expedite.

POLICY UPDATE CHANGES

No material clinical/coverage changes — this is an administrative prior authorization intake form; has_material_change=false.

1Form type (prior authorization)

2Epkinly vial strengths listed

6Diagnosis options provided

Policy overview

Subject: Prior Authorization Request Form for Epkinly (epcoritamab). Doc type: administrative.

Background: This is a Cigna prior authorization intake form specific to Epkinly (epcoritamab) used to collect administrative, clinical, and dispensing information required for Cigna to process coverage requests. The form captures patient and prescriber details, clinical history, diagnosis, medication selection (including Epkinly 4mg/0.8mL and Epkinly 48mg/0.8mL), directions for use, quantity/duration, and dispensing location.

Form completion and required information

Form Completion / Information Required

Complete all required fields on the form. Cigna will not respond via fax with the outcome of the review unless all asterisked (*) items on this form are completed.

ALL of the following

Fax completed form to: (855) 840-1678.
If URGENT, call (800) 882-4462 (800.88.CIGNA).
Complete all asterisked (*) patient and physician fields (e.g., Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address).
Due to privacy regulations Cigna will not respond via fax unless all asterisked items are completed.
Provide office contact, office phone and fax, and office street address (city, state, zip).
Indicate urgency: Standard or Urgent (attestation required if Urgent).
Specify medication requested (Epkinly 4mg/0.8mL or 48mg/0.8mL), ICD-10, directions for use, quantity, and duration of therapy.
State whether medication is for a chronic/long-term condition (Yes/No).
Where will medication be obtained? Select one: Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, Physician's office stock (billing on a medical claim form), or Other (specify).
Accredo is Cigna's nationally preferred specialty pharmacy. Medication orders can be placed with Accredo via E-prescribe (NCPDP 4436920), Fax 888.302.1028, or Verbal 866.759.1557.
If facility/doctor will dispense/ administer, provide facility name, state, tax ID, address (city, state, zip).
Indicate whether patient is a candidate for home infusion and whether physician has an in-office infusion site (Yes/No).
Provide diagnosis related to use (select applicable lymphoma diagnosis or Other with specification).
Complete clinical information: prior systemic therapy (Yes/No), number of different lines tried (Only 1 or 2 or more), whether this is the only medication to be used now (Yes/No).
If Follicular Lymphoma (FL), indicate whether disease is relapsed or refractory (Yes/No).
Preserve FL-specific relapsed/refractory item.
Provide additional pertinent information including disease stage, prior therapy, performance status, and names/doses/admin schedule of any agents to be used concurrently.
Attestation: prescriber must attest that information is true and accurate. Health Plan may perform routine audit and request medical information to verify accuracy.
Prescriber signature and date required.

Documentation Required

Complete all required fields and asterisked items

Complete all required fields and any asterisked items on the form. Cigna will not respond via fax with the outcome of the review unless all asterisked items are completed.

Fax completed form to: (855) 840-1678
If urgent, also call (800) 882-4462

Documentation Required

Prescriber attestation and signature

Prescriber must attest to the accuracy of the information and provide a handwritten or electronic signature and date. The Health Plan may perform routine audits and request medical records to verify the information reported on this form.

Prescriber signature and date required
Attestation that information provided is true and accurate
Audits and medical record requests may be made to verify the request

Submission, contact, and processing timeline

Submission / Contact Instructions

How to submit and expected response times

Fax number: Fax completed form to: (855) 840-1678.
Urgent call requirement: If URGENT, call (800) 882-4462 in addition to faxing.
Accredo order methods: Medication orders can be placed with Accredo via E-prescribe (NCPDP 4436920), Fax 888.302.1028, or Verbal 866.759.1557.
Online submission options: Save time: submit online at covermymeds.com or via SureScripts in EHR.
Response times: Standard response time for prescription drug coverage requests is 5 business days; urgent requests should be called to expedite.

Prior Authorization

Submit prior authorization request

Fax the completed prior authorization form to (855) 840-1678. If the request is URGENT, call (800) 882-4462 in addition to faxing to expedite the review.

Billing Rule

Site of care and dispensing selection required

Provider must indicate where the medication will be obtained (options include Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, Physician's office stock, or Other) and provide facility/dispensing details (facility name, state, Tax ID, address).

Documentation Required

Clinical history and prior therapy required

Provide clinical history including whether the patient received systemic therapy, number of prior lines of systemic therapy, whether this is the only medication being used now, and (for follicular lymphoma) whether disease is relapsed or refractory. Also include additional pertinent information such as disease stage, prior therapy, performance status, and names/doses/administration schedule of any concurrent agents.

Codes and selections on the form

Medication product selections on formmixed

Epkinly 4mg/0.8mL	Form selection for Epkinly 4mg/0.8mL solution for injection
Epkinly 48mg/0.8mL	Form selection for Epkinly 48mg/0.8mL solution for injection

Diagnosis options listed on form (ICD10 to be provided by prescriber)ICD-10

	Diffuse large B-cell lymphoma (DLBCL) - ICD-10 to be specified by prescriber
	Follicular lymphoma (FL) - ICD-10 to be specified by prescriber
	High grade B cell lymphoma - ICD-10 to be specified by prescriber
	Histologic transformation of Indolent Lymphoma to DLBCL - ICD-10 to be specified by prescriber
	HIV-related B-cell lymphoma - ICD-10 to be specified by prescriber
	Post-transplant lymphoproliferative disorder (PTLD) - ICD-10 to be specified by prescriber
	Other - ICD-10 to be specified by prescriber

Preferred specialty pharmacymixed

Accredo (NCPDP 4436920)

Cigna's nationally preferred specialty pharmacy

OpenPayer

prior_authorization_request_form_epkinly

Policy overview

Form completion and required information

Submission, contact, and processing timeline

Codes and selections on the form

Definitions

Revision history