Cigna rituximab Prior Auth Coverage

Indication-specific Coverage Criteria

Indication-specific coverage branches

Coverage depends on indication-specific criteria collected on the form; examples below reflect the condition-specific branches present on the form:

Indication selection: Request must specify one of the listed indications (oncology and non-oncology) and provide indication-specific answers on the form.

See form for full list of indications.

CLL/SLL specific: For CLL/SLL, document relapsed/refractory status and del(17p)/TP53 mutation status; indicate use with high-dose methylprednisolone if applicable.

Follicular lymphoma: For FL, indicate place in therapy (maintenance after response, previously untreated, or relapsed/refractory) and whether single-agent or combined with chemotherapy or lenalidomide/tafasitamab-cxix.

ANCA-associated vasculitis: Specify induction vs follow-up; if induction, confirm specialist involvement and combination with glucocorticoids; if follow-up, document disease control and interval >=16 weeks between courses.

Graft-versus-host disease: If no prior rituximab, confirm chronic GVHD and specialist prescribing/consult; document trial of at least one systemic medication; if prior rituximab, document objective beneficial response or symptom improvement.

ITP: Specify initial treatment vs prior course; if initial, confirm hematology involvement and trial of one other therapy; if prior course, ensure >=6 months since previous course and document response/relapse per prescriber.

Immunotherapy-related toxicity: Confirm specialist involvement, whether initial therapy or prior rituximab, development of toxicity while on checkpoint inhibitor, and symptomatic despite trial of at least one systemic corticosteroid for initial therapy.

Hematopoietic cell transplantation: If used as part of conditioning for allogeneic transplant, confirm oncologist/hematologist or transplant-affiliated prescriber involvement.

Immune Thrombocytopenia (ITP)

Covered when ALL of the following are met for Immune Thrombocytopenia (ITP):

ITP - prescriber specialty: Medication is prescribed by or in consultation with a hematologist (for initial treatment).

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ITP - prior therapy or prior rituximab: Either initial treatment after trial of at least one other therapy OR patient has already received a course of rituximab; if already received, at least 6 months must elapse between courses; document response and relapse status as applicable.6 months between courses when re-treating

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Immunotherapy-Related Toxicities Associated with Checkpoint Inhibitors

Covered when ALL of the following are met for Immunotherapy-Related Toxicities:

Specialty: Medication prescribed by or in consultation with an oncologist, hematologist, nephrologist, neurologist, rheumatologist, or dermatologist.

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Toxicity related to checkpoint inhibitor: Prescriber states patient developed an immunotherapy-related toxicity while receiving a checkpoint inhibitor and symptomatic despite a trial of at least one systemic corticosteroid.trial of ≥1 systemic corticosteroid

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Interstitial Lung Disease associated with Systemic Autoimmune Rheumatic Disease

Covered when ALL of the following are met for Interstitial Lung Disease associated with systemic autoimmune rheumatic disease:

Specialty: Medication prescribed by or in consultation with a pulmonologist or rheumatologist.

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Initial or prior rituximab: Either initial treatment with HRCT-confirmed diagnosis or patient has already received a course of rituximab; if re-treatment, at least 24 weeks must elapse and evidence of beneficial response should be documented.24 weeks between courses when re-treating

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Membranous Nephropathy

Covered when ALL of the following are met for Membranous Nephropathy:

Risk and specialty: Patient is at moderate or high risk for progressive loss of kidney function and medication is prescribed by or in consultation with a nephrologist.

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Minimal Change Disease

Covered when ALL of the following are met for Minimal Change Disease:

Indication and specialty: Medication is used for frequently relapsing or steroid-dependent disease and is prescribed by or in consultation with a nephrologist.

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Multiple Sclerosis (MS)

Covered when ALL of the following are met for Multiple Sclerosis (MS):

Specialty: Medication prescribed by or in consultation with a neurologist or an MS specialist.

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Concomitant therapy and prior DMTs: If starting, verify whether used in combination with another MS disease-modifying therapy; if not currently receiving rituximab, patient must have had inadequate efficacy or significant intolerance to at least two other disease-modifying agents; re-treatment courses must be ≥6 months apart.≥2 prior DMTs for new users; 6 months between courses for re-treatment

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Clinical benefit: If on therapy ≥1 year, document beneficial clinical response by at least one objective measure; if no objective response, document stabilization or improvement in at least one symptom.

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Myasthenia Gravis (MG)

Covered when ALL of the following are met for Myasthenia Gravis (MG):

Specialty: Medication prescribed by or in consultation with a neurologist.

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Prior treatment and antibody status: If no prior rituximab: patient must have confirmed anti-MuSK antibody-positive MG, have tried pyridostigmine (or have contraindication/intolerance), and have tried at least one immunosuppressant; if prior rituximab, document continued benefit.

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Neuromyelitis Optica (NMO) Spectrum Disorder

Covered when ALL of the following are met for Neuromyelitis Optica (NMO) Spectrum Disorder:

Specialty: Medication prescribed by or in consultation with a neurologist.

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Pediatric Nephrotic Syndrome

Covered when ALL of the following are met for Pediatric Nephrotic Syndrome:

Specialty: Medication prescribed by or in consultation with a nephrologist.

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Prior therapy: If no prior rituximab course: patient must have tried at least one systemic corticosteroid; if corticosteroid trial absent, document trial of at least one glucocorticoid-sparing agent.

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Pemphigus Vulgaris

Covered when ALL of the following are met for Pemphigus Vulgaris:

Specialty: Medication prescribed by or in consultation with a dermatologist.

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Initial/relapse/maintenance rules: If initial, rituximab should be initiated in combination with a corticosteroid unless contraindicated; for relapse or maintenance, subsequent infusions must be at least 16 weeks apart.16 weeks between courses for relapse/maintenance

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Rheumatoid Arthritis (RA)

Covered when ALL of the following are met for Rheumatoid Arthritis (RA):

Combination therapy and specialty: Specify whether used in combination with a biologic or targeted synthetic DMARD; if no prior rituximab courses, medication must be prescribed by or in consultation with a rheumatologist and patient must have tried one conventional synthetic DMARD for ≥3 months and one non-requested biologic for ≥3 months (biosimilars do not count).3 months trials for DMARDs/biologics

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Re-treatment and response: For prior rituximab recipients, ≥16 weeks must have elapsed since prior course; if patient has received ≥2 prior courses, document beneficial clinical response using objective disease activity measures or symptom improvement.16 weeks between courses

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Solid Organ Transplantation

Covered when ALL of the following are met for Solid Organ Transplantation:

Transplant use: Indicate intended use: desensitization prior to or immediately after transplant, or treatment of antibody-mediated rejection. If not for desensitization, document transplant-center affiliation, and confirm prescribed dose follows transplant center protocol.

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Systemic Lupus Erythematosus (SLE)

Covered when ALL of the following are met for Systemic Lupus Erythematosus (SLE):

Initial vs prior course: If initial therapy: medication prescribed by or in consultation with a rheumatologist, nephrologist, or neurologist and patient has tried at least one standard immunomodulating or immunosuppressant agent; if prior rituximab, ≥6 months must elapse between courses.6 months between courses for re-treatment

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Thrombotic Thrombocytopenic Purpura (TTP)

Covered when ALL of the following are met for Thrombotic Thrombocytopenic Purpura (TTP):

Combination therapy and specialty: Medication will be used in combination with systemic corticosteroids and therapeutic plasma exchange, and is prescribed by or in consultation with a hematologist.

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For many non-oncology indications the completed form requires attached medical documentation showing that the patient has tried all of the listed formulary alternative rituximab products: Truxima, Riabni, and Ruxience. The documentation must be patient-specific (for example, chart notes, laboratory tests, or claims records) and accompany the prior authorization; requests without this documentation may be denied.

Coverage details and which rituximab product is preferred can vary by patient plan. Providers should check applicable Cigna resources (for example, the Cigna HCP site referenced on the form) for benefit availability, plan-specific preferred products, and the terms and conditions of coverage when submitting requests.

first-line | continuation | maintenance

Line of therapy: Form captures whether rituximab is requested as first-line, continuation, or maintenance (e.g., FL maintenance after response).

del(17p)/TP53 biomarker requirement flag

DefinitionPresence or absence of del(17p)/TP53 mutation as asked on the CLL/SLL form (Yes/No).

PurposeUsed to inform disease prognosis and guide use of rituximab in relapsed/refractory CLL/SLL.

Form field locationCaptured in the CLL/SLL indication section where prescriber indicates relapsed or refractory status and concurrent HDMP use.

Submission, Documentation, and Prior Authorization Actions

Prior Authorization

Submission and pharmacy routing — prior authorization fax/phone and Accredo preferred specialty pharmacy designation

Prior Authorization Required — Fax or call for urgent requests. Fax completed form to: (855) 840-1678. If this is an URGENT request, call (800) 882-4462 (800.88.CIGNA). Orders may be routed to Cigna's nationally preferred specialty pharmacy, Accredo. Accredo contact: E-prescribe NCPDP 4436920 (Accredo, 1620 Century Center Pkwy, Memphis, TN 38134-8822), Fax 888.302.1028, Verbal 866.759.1557. If medication will be obtained at hospital outpatient, retail, physician office stock, home infusion, or other vendor, indicate on the form.

Fax: (855) 840-1678
Urgent phone: (800) 882-4462
Accredo (preferred specialty pharmacy) contacts: E-prescribe NCPDP 4436920; Fax 888.302.1028; Phone 866.759.1557

Documentation Required

Complete indication-specific authorization checklist — requirement to complete checklists documenting prior therapies, prescriber specialty/consultation, and supporting docs

Complete the indication-specific authorization checklist on the form and attach supporting medical documentation. For each applicable diagnosis section (for example ITP, MS, RA, SLE, transplant, pediatric nephrotic syndrome, pemphigus vulgaris, etc.), indicate whether the request is initial therapy or continuation, prescriber specialty or consultation, prior therapy trials, timing since prior rituximab courses (when applicable), and objective response or relapse information.

Definitions and Objective Response Measures

ANCA-associated vasculitis (AAV)

ExamplesIncludes granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA).

Induction vs Follow-up distinctionForm asks whether request is for induction treatment OR follow-up treatment after induction (which may have used rituximab or other standard immunosuppressants).

Induction requirementsIf induction, prescriber must be a rheumatologist, nephrologist, pulmonologist, or immunologist and indicate combination with glucocorticoids.

Follow-up requirementsIf follow-up, prescriber must document disease control after induction and confirm at least 16 weeks will elapse between courses.

CLL/SLL relapsed or refractory

Relapsed/Refractory statusForm asks: Does the patient have relapsed or refractory disease? (Yes/No).

Background and Scope

Rituximab is used across multiple hematologic malignancies, autoimmune diseases, and transplant-related conditions. The prior authorization form collects indication-specific details—such as disease status (e.g., relapsed/refractory), mutation or biomarker findings where relevant (for example del(17p)/TP53 in CLL/SLL), prior rituximab exposure and timing since prior courses, and specialist involvement or consultation—so that coverage decisions follow the clinical context for the requested indication.

The form lists approximately 20 selectable indications, covering oncology uses (for example, acute lymphoblastic leukemia, CLL/SLL, follicular lymphoma, and other B‑cell malignancies) as well as a broad set of non‑oncology autoimmune and transplant-related conditions (for example, ANCA‑associated vasculitis, ITP, MS, SLE, membranous nephropathy, and TTP). It captures whether the request is for initial therapy, re‑treatment, maintenance, or use as part of transplant conditioning, and requests documentation of prior therapies, objective measures of response where applicable, and prescriber specialty to support medical necessity.

OpenPayer

Rituximab prior authorization and coverage

Indication-specific Coverage Criteria

Submission, Documentation, and Prior Authorization Actions

Definitions and Objective Response Measures

Background and Scope