CurrentCignaPolicy V080124

Apretude (cabotegravir) prior authorization – prior authorization request form for PrEP and HIV treatment

This document is a Cigna prior authorization request form for Apretude (cabotegravir) describing information required from providers to request coverage for PrEP or HIV treatment administration routes and dispensing locations. It affects prescribers, pharmacies, and facilities submitting authorization for this medication.

Policy Summary

PayerCigna

PolicyApretude (cabotegravir) prior authorization – prior authorization request form for PrEP and HIV treatment

Policy CodePolicy V080124

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax completed prior authorization form to (855) 840-1678 and include required patient and prescriber identifiers plus clinical attestation (weight ≥35 kg, negative HIV-1 test within 1 week, no acute infection signs).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

855-840-1678fax number to submit completed form

35 kgminimum weight queried for PrEP

1 weekmax interval for negative HIV-1 test

5 business daysstandard response time

Coverage Criteria for Apretude (cabotegravir)

PrEP attestation criteria

Information requested for PrEP consideration (provider must attest to these clinical conditions):

PrEP baseline checks: Patient weighs >= 35 kg>= 35 kg

Captured on form under Clinical Information (if PrEP).

PrEP baseline checks: Medication will be administered only if the patient has a negative HIV-1 test result no more than 1 week prior to the dosenegative HIV-1 test within 1 week

Captured on form under Clinical Information (if PrEP).

PrEP baseline checks: Patient has no signs or symptoms of acute HIV infection, according to the prescriber

Policy Summary

PayerCigna

PolicyApretude (cabotegravir) prior authorization – prior authorization request form for PrEP and HIV treatment

Policy CodePolicy V080124

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Provider Submission Requirements and Actions

Prior Authorization

Prior Authorization Required

Prior authorization submission and medication sourcing: Fax the completed prior authorization form to (855) 840-1678. For urgent requests call (800) 882-4462 (800.88.CIGNA). You may also submit online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. Medication sourcing options must be indicated on the form.

Include medication requested and directions for use (dose, quantity, duration).
Indicate ICD-10 diagnosis code and relevant clinical information.

Note

Dispensing Vendor Selection

Dispensing vendor selection: Indicate where the medication will be obtained by selecting one of the options on the form. Cigna’s nationally preferred specialty pharmacy (Accredo) is listed and available for orders; Accredo contact options are provided to place orders directly.

Accredo Specialty Pharmacy (preferred) — NCPDP 4436920; E-prescribe, Fax 888.302.1028, Verbal 866.759.1557.
Other options: Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion vendor, Physician's office stock (billing on a medical claim form), or Other (specify).

Documentation Required

Required Documentation and Clinical Attestation

Required documentation and clinical attestation: Complete all asterisked (*) patient and prescriber fields on the form (physician name, DEA/NPI or TIN, patient name, Cigna ID, date of birth, patient address, etc.). Provide facility/doctor dispensing details when applicable, diagnosis selection (PrEP vs treatment), and full clinical information (weight if PrEP, HIV test timing, signs/symptoms screening, prevention strategy, specialist consultation). The prescriber must sign and date the attestation confirming the accuracy of the information.

Patient identifiers required: * Patient Name, * Cigna ID, * Date of Birth, * Patient Street Address.
Prescriber identifiers required: * Physician Name, * DEA, NPI or TIN, Specialty, Office contact, Office phone/fax/address.
Clinical fields required: Medication requested, ICD-10 code, directions for use (dose, quantity, duration), PrEP-specific questions (weight, recent negative HIV-1 test within 1 week, absence of acute HIV symptoms, comprehensive prevention strategy), and additional pertinent information (current therapy, how supplied, dates).
Attestation and prescriber signature/date are required for submission.

Denial Risk

Incomplete Fields May Prevent Outcome Notification

Incomplete required fields may prevent communication of the outcome: The plan will not be able to respond via fax with the outcome of the review unless all asterisked fields are completed. Missing required information may delay or prevent adjudication — if the request is urgent, call to expedite.

Ensure all asterisked fields are filled to receive faxed outcomes.
Standard response time: 5 business days; call for urgent processing.

Definitions and Key Terms

Apretude (cabotegravir)

Medication identifiedApretude (cabotegravir) — injectable formulation listed on the form

Requested medication optionApretude 600 mg/3 mL (200 mg/mL) vial appears as the medication requested on the form

Usage contextsReferenced for use as PrEP of HIV-1 infection and for treatment of HIV on the form

PrEP clinical checks

Weight checkPatient weighs 35 kg or more (required for PrEP)

HIV-1 test recencyNegative HIV-1 test result no more than 1 week prior to the dose (required)

Acute infection screenNo signs or symptoms of acute HIV infection per prescriber (required)

Prevention planMedication prescribed as part of a comprehensive HIV-1 prevention strategy (adherence plan and safer sex practices) (required)

Specialist involvementPrescribed by or in consultation with an HIV specialist (required)

OpenPayer

Apretude (cabotegravir) prior authorization – prior authorization request form for PrEP and HIV treatment

Coverage Criteria for Apretude (cabotegravir)

Coding and Clinical Thresholds

Provider Submission Requirements and Actions

Definitions and Key Terms

Background