CurrentCignaPolicy N/A

Korsuva (difelikefalin) prior authorization for CKD-associated pruritus

This document is a Cigna prior authorization form for requesting coverage of Korsuva (difelikefalin) injection for patients with chronic kidney disease-associated pruritus on hemodialysis or peritoneal dialysis. It governs prescribers requesting medical-benefit coverage and applies to Cigna members covered by the payer.

Policy Summary

PayerCigna

PolicyKorsuva (difelikefalin) prior authorization for CKD-associated pruritus

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with patient and prescriber information, documentation of moderate-to-severe pruritus, and prior therapy trial details or contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

Korsuva 65mcg/1.3 mLform lists medication and strength

Fax and phonesubmission channels (fax and phone for urgent)

Nephrologist involvementform asks whether prescribed by or in consultation with a nephrologist

Coverage Criteria for Korsuva (difelikefalin)

Initial Authorization

Covered when ALL of the following are met:

Initial authorization criteria

Patient has a diagnosis of chronic kidney disease-associated pruritus in hemodialysis or peritoneal dialysis.
Select the appropriate dialysis-related diagnosis on the form.
Patient has moderate-to-severe pruritus as documented on the form ( clinician must indicate 'Yes' to moderate-to-severe pruritus).
Prior therapy requirement
- Provider documents trial and inadequate response to at least one covered alternative (topical emollient; gabapentin; an oral antihistamine such as diphenhydramine, hydroxyzine, or loratadine; or pregabalin).
  Include drug name, strength, dates taken, duration, documented results, and any intolerances or adverse reactions.

Policy Summary

PayerCigna

PolicyKorsuva (difelikefalin) prior authorization for CKD-associated pruritus

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with patient and prescriber information, documentation of moderate-to-severe pruritus, and prior therapy trial details or contraindications.

SourceLink

On This Page

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Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Korsuva (difelikefalin) injection. Submit the completed prior authorization form by fax to (855) 840-1678, online via CoverMyMeds (www.covermymeds.com/main/prior-authorization-forms/cigna/), or through SureScripts in your EHR. If this is an urgent request, call (800) 882-4462. Our standard response time is 5 business days; urgent requests should be called in to expedite.

Standard response time: 5 business days
Urgent requests: call (800) 882-4462

Step Therapy

Step Therapy: Trial of Covered Alternatives Required

Provider must document that the patient has tried at least one covered alternative therapy prior to approval. Covered alternatives include: topical emollient; gabapentin; oral antihistamine (for example, diphenhydramine, hydroxyzine, loratadine); or pregabalin. For each alternative tried, include drug name and strength, dates taken, duration, documented clinical response, and any intolerances or adverse reactions. If an alternative was not tried, provide clinical justification (e.g., contraindication).

At least one covered alternative must be tried before approval
Document dates, duration, response, and adverse reactions for alternatives tried
If not tried, document medical reason/contraindication

Documentation Required

Provider Submission Details — Complete Patient & Prescriber Information

Submit a fully completed patient and prescriber section on the prior authorization form. Required patient and prescriber information includes: physician name and specialty; DEA, NPI, or TIN; office contact, phone and fax; patient name, Cigna ID, date of birth, address, and phone. Also include diagnosis and ICD-10 code(s), medication requested (dose, directions, quantity, duration), start date, whether this is a new start or continuation, and documentation of benefit if continuation.

Prescriber identifiers required: DEA, NPI or TIN
Include Cigna ID and patient DOB
Provide diagnosis and ICD-10 code(s), dose, quantity, directions, duration, and start date

Denial Risk

Denial Risk: Incomplete Documentation May Lead to Denial

Failure to document a trial of at least one covered alternative, or inadequate documentation of response or intolerance to that alternative, may result in denial of the prior authorization request. Ensure attestation is signed and retain supporting clinical records; the plan or its designees may audit requests and request additional medical information.

Incomplete documentation of trials/intolerance or missing attestation risks denial
Be prepared to provide supporting clinical notes and lab values upon audit

Definitions

Chronic Kidney Disease-Associated Pruritus — definition and dialysis context

DefinitionPruritus occurring in patients with chronic kidney disease who are receiving dialysis, specified as either hemodialysis-associated or peritoneal dialysis-associated pruritus.

Dialysis settings listed on formChronic Kidney Disease Associated Pruritus in Hemodialysis; Chronic Kidney Disease-Associated Pruritus in Peritoneal Dialysis.

Required documentation of symptom severityForm asks whether the patient has moderate-to-severe pruritus (Yes/No).

Relation to treatment eligibilityCoverage consideration requires documentation of moderate-to-severe pruritus and prior therapies tried or contraindications to alternatives.

Nephrology involvementForm asks if the requested medication is prescribed by, or in consultation with, a nephrologist (Yes/No).

OpenPayer

Korsuva (difelikefalin) prior authorization for CKD-associated pruritus

Coverage Criteria for Korsuva (difelikefalin)

Coding and Billing Codes

Provider Actions and Submission Requirements

Background

Definitions