CurrentCignaPolicy N/A

Prior Authorization Request Form for Imaavy (generalized myasthenia gravis)

A Cigna prior authorization request form to obtain coverage determination for the medication Imaavy, capturing patient, prescriber, clinical indication (generalized myasthenia gravis), treatment status (new or continuation), diagnostic and prior therapy documentation, site of administration, and pharmacy dispensing details.

Policy Summary

PayerCigna

PolicyPrior Authorization Request Form for Imaavy (generalized myasthenia gravis)

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests require a phone call to (800) 882-4462.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — the document is an administrative prior authorization request form and contains no policy changes.

1Primary Indication Captured

1Preferred Specialty Pharmacy

5Key Clinical Documentation Items Required

Policy summary

This is a Cigna prior authorization request form to collect administrative and clinical data necessary to evaluate coverage for Imaavy, primarily for generalized myasthenia gravis. The form captures patient identifiers and contact information, prescriber details (including specialty and DEA, NPI or TIN), and medication-specific information such as dose, frequency, duration, and current weight. It also records whether the request is a new start or a continuation of therapy and allows indication selection.

Key clinical data requested include antibody status (anti-acetylcholine receptor and, if negative, anti-MuSK), Myasthenia Gravis Foundation of America (MGFA) classification, Myasthenia Gravis Activities of Daily Living (MG-ADL) score, prior therapy history (including pyridostigmine use or intolerance), evidence of unresolved MG symptoms, and whether the medication is being used with other agents (neonatal Fc receptor blockers, complement inhibitors, or rituximab).

The form also collects administration and dispensing details such as the site of administration (home, physician office, hospital outpatient, other) and where the medication will be obtained, including preference for Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy). Submission instructions are administrative: fax the completed form to (855) 840-1678 or, for urgent requests, call (800) 882-4462; online submission via CoverMyMeds or SureScripts is also noted.

Authorization Summary

PayerCigna

Document typePrior Authorization Request Form

Primary indication capturedGeneralized myasthenia gravis (Primary Indication Captured: 1)

Preferred Specialty PharmacyAccredo (Cigna's nationally preferred specialty pharmacy)

Key clinical documentation items requiredAntibody status, MGFA class, MG-ADL score, prior therapy history, evidence of unresolved symptoms (5 items)

Coverage stanceInformational

StatusCURRENT

Authorization information collected on form

Authorization Information Collected

Form collects required clinical and administrative items to support a prior authorization decision for Imaavy:

Patient and Prescriber Identification
- Prescriber Information: Prescriber information including specialty and DEA, NPI or TIN; office contact and phone/fax.
Medication and Treatment Details: Medication requested (Imaavy), dose, frequency, duration, and current weight; indicate new start or continuation of therapy.
Pharmacy Source and Dispensing: Specify source of medication (Accredo Specialty Pharmacy, retail, hospital outpatient, prescriber's office stock, home health/home infusion vendor, other) and facility/dispensing entity; administration site (home, physician office, hospital outpatient, other).
Urgency indicator (Standard or Urgent) with attestation required when Urgent is selected.
Indication/diagnosis selection: Generalized myasthenia gravis or all other indications or diagnoses.
Concomitant Therapies: Whether medication will be used concomitantly with another neonatal Fc receptor blocker, complement inhibitor, or rituximab product (Yes/No).
Neurology Involvement: Whether prescribed by or in consultation with a neurologist (Yes/No).
Current Imaavy Therapy: If currently receiving Imaavy: Is patient deriving benefit? (Yes/No).
Examples of derived benefit include reductions in exacerbations and improvements in speech, swallowing, mobility, and respiratory function.
Age and MGFA Requirement
- MG-ADL Score: MG-ADL score >= 6 (Yes/No).MG-ADL >= 6
  Medical documentation must be attached or request could be denied.
- Anti-AChR Antibody: Documentation of confirmed anti-acetylcholine receptor antibody-positive generalized myasthenia gravis is provided (Yes/No).
  Medical documentation must be attached or request could be denied.
- Anti-MuSK Antibody: If anti-AChR negative: documentation of anti-MuSK antibody-positive generalized myasthenia gravis provided (Yes/No).
  Medical documentation must be attached or request could be denied.
- Unresolved Symptoms:
Attestation and prescriber signature/date certifying accuracy and permitting audits.
The prescriber attests the information is true and understands the plan may perform routine audits and request medical information.

What providers must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via CoverMyMeds or through SureScripts in your EHR. If this is an urgent request, you must also call (800) 882-4462 to expedite the review.

Documentation Required

Attach supporting medical documentation

Attach supporting medical documentation such as chart notes, laboratory tests, medical test results, claims records, or prescription receipts to confirm antibody positivity (anti‑AChR or, if negative, anti‑MuSK), MGFA classification, MG‑ADL score, and prior therapy intolerance or inadequate efficacy. Requests may be denied if the required documentation is not attached.

Billing Rule

Specialty pharmacy preference

Cigna's nationally preferred specialty pharmacy is Accredo. Medication orders can be placed with Accredo via e‑prescribe, fax, or verbal order per the contact details provided on the form.

Accredo is Cigna's nationally preferred specialty pharmacy
Ordering options: e‑prescribe, Fax, Verbal

Documentation Required

Site of infusion selection and redirection note

Document whether the patient is a candidate for re-direction to a less intensive infusion setting (for example, alternate infusion site, physician's office, or home) per plan requirements. If the patient is not appropriate for a less intensive setting, provide a medical necessity rationale in the record.

Relevant code systems

ICD-10ICD-10

No codes listed

Key definitions

Definitions

MG-ADL (Myasthenia Gravis Activities of Daily Living)Score used on form; threshold: >= 6

MGFA (Myasthenia Gravis Foundation of America classification)Clinical classification used on form (MGFA II to IV queried for patients 18+ not currently receiving Imaavy)

This form is administrative and designed to collect information for a prior authorization determination; it is not a coverage policy. It is informational in nature and requests supporting medical documentation (lab results, chart notes, test results, claims records, or prescription receipts) for items such as antibody positivity, MGFA classification, MG-ADL score, and prior therapy intolerance or inadequate efficacy.

Attestation and prescriber signature are required to certify the accuracy of the information and permit audits. Urgent requests require a phone call to the number provided to expedite review.

Policy Summary

PayerCigna

PolicyPrior Authorization Request Form for Imaavy (generalized myasthenia gravis)

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests require a phone call to (800) 882-4462.

SourceLink

On This Page

Evidence of unresolved symptoms of generalized myasthenia gravis (e.g., difficulty swallowing, breathing, or functional disability) (Yes/No).

Examples include difficulty swallowing, breathing, or functional disability resulting in discontinuation of physical activity.

Pyridostigmine Prior Therapy: Prior therapy with pyridostigmine (Yes/No).

If pyridostigmine not received: documentation of inadequate efficacy, contraindication, or significant intolerance to pyridostigmine (Yes/No).

OpenPayer

Prior Authorization Request Form for Imaavy (generalized myasthenia gravis)

Policy summary

Authorization information collected on form

What providers must do

Relevant code systems

Key definitions

Document changes