CurrentCignaPolicy N/A

Multiple Sclerosis: Aubagio, Avonex, Bafiertam DR, Betaseron, Copaxone, Extavia, Gilenya, Glatiramer, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus

Cigna prior authorization / medication request form for multiple sclerosis disease-modifying therapies (list of specified agents) to collect patient, diagnosis, prior treatment, intolerance/contraindication, and site-of-care information to support coverage determination and utilization management.

Policy Summary

PayerCigna

PolicyMultiple Sclerosis: Aubagio, Avonex, Bafiertam DR, Betaseron, Copaxone, Extavia, Gilenya, Glatiramer, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus

Policy CodePolicy N/A

Change TypeVersion identifier only (v010124); no material changes

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

v010124 appears as a version identifier at document end indicating update date/version.

20+Drugs listed on form

5 business daysStandard response time

855-840-1678Fax to submit form

800-882-4462Urgent request phone

This is a Cigna prior-authorization / medication request form for multiple sclerosis disease-modifying therapies. The form lists many requestable agents (for example: Aubagio, Avonex, Bafiertam DR, Betaseron, Copaxone, Extavia, Gilenya, glatiramer products, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus, Plegridy, Rebif, Tecfidera, Tysabri, Vumerity, Zeposia) and collects clinical, administrative, and prior-treatment information to determine medical necessity and benefit coverage. Approval and benefit availability are plan-specific and subject to applicable Cigna clinical coverage policies and the member's formulary/benefit terms; coverage decisions may vary by plan.

Key stats

Drugs listed on form20+

Standard response time for prescription drug coverage requests5 business days

Fax number to submit form855-840-1678

Phone for urgent requests800-882-4462

Form: Required Clinical and Administrative Criteria

General Prior Authorization Information

Form collects required information for review; approvals contingent on meeting plan-specific clinical coverage policies and formulary/benefit availability.

Patient identifying information completed for all items marked with an asterisk (*)
See patient information section for required asterisked fields (Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, DOB, Patient Street Address, etc.)
Medication requested must be one of the listed MS therapies (Aubagio, Avonex, Bafiertam DR, Betaseron, Copaxone, Extavia, Gilenya, glatiramer, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus, Plegridy, Rebif, Tecfidera, Tysabri, Vumerity, Zeposia, or other specified)
Dose, quantity, duration, J-code, frequency, and ICD-10 diagnosis code must be specified
Dose/quantity/duration/diagnosis: Specify dose, quantity, duration, J-code, frequency of administration, and ICD-10 diagnosis code
New vs continuation: Indicate whether request is new start or continuation of therapy
If new start after samples, choose new start of therapy
If continued therapy: If continuation, indicate prior approvals or duration of regular use and provide dates of prior treatment (including date of last Lemtrada dose if applicable)
Options include previous approval by another plan, regular use >1 year, restarting after break
Site of obtaining and administering: Specify site where medication will be obtained (Accredo specialty pharmacy, hospital outpatient, retail, home infusion, physician office stock, other) and site where medication will be administered (patient's home, physician's office, hospital outpatient, other)
Per some plans infusion must occur in least intensive appropriate setting; provide facility/doctor dispensing and administering details as requested
Diagnosis selection: Provide diagnosis selection (CIS, RRMS, PPMS, PRMS, active SPMS with relapses, active SPMS with new brain lesions, other non-relapsing forms, or other)
Clinical information and rationale: Provide clinical information including concurrent/previous MS therapies, whether drug will be stopped or added, names/dates and clinical rationale for combined use
Document prior failures/intolerances/contraindications: Document prior failures, inadequate responses, intolerances, or contraindications to listed therapies as applicable and provide dates and detailed reasons/results for each drug tried
Includes checkboxes for each listed agent and request to provide details for all drugs checked
If requesting Lemtrada or Tysabri
- Highly-active or aggressive disease - deterioration: Document highly-active or aggressive disease shown by rapidly-advancing deterioration in physical functioning (e.g., loss of mobility, severe changes in strength or coordination) (Yes/No)
- Disabling relapse with suboptimal steroid response: If no deterioration, document disabling relapse(s) with suboptimal response to systemic corticosteroids (Yes/No)
- MRI findings: If neither, document MRI findings suggesting highly-active or aggressive MS (new, enlarging, or high burden of T2 lesions or gadolinium‑enhancing lesions) (Yes/No)
- Cognitive impairment: If none of the above, document cognitive impairment related to MS (deficits in short‑term or long‑term memory, visual spatial deficits) (Yes/No)
Prescriber attestation and signature: Prescriber attestation that information is true and accurate, with prescriber signature and date

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Actions for Providers / Submission Instructions

Prior Authorization

Submit completed prior authorization form

Fax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests require phone call to expedite.

Documentation Required

Complete all required patient/clinical fields

All asterisked (*) patient information fields must be completed for Cigna to respond; include prior treatment dates, intolerance/contraindication details and prescriber signature.

Documentation Required

Site-of-care and pharmacy sourcing

Specify where medication will be obtained (Accredo specialty pharmacy, retail, hospital outpatient, physician office stock, home infusion) and where it will be administered; infusion may be required in least intensive appropriate setting per some plans.

Billing Rule

Include NDC on medical claims for Betaseron

NDC number is required on medical claims to confirm claim is payable for the drug Betaseron; refer to Cigna crosswalk of HCPCS codes requiring NDC.

Betaseron NDC required

Denial Risk

Benefit/plan-specific coverage may deny

Coverage is subject to the member's specific plan formulary and terms; refer to Cigna health care professional resources for benefit availability and coverage terms.

Definitions and Background

CIS — Clinically isolated syndrome.

RRMS — Relapsing forms of multiple sclerosis.

PPMS — Primary progressive multiple sclerosis.

PRMS — Primary-relapsing multiple sclerosis.

SPMS — Secondary progressive multiple sclerosis (documented on form as “active SPMS with relapses” or “active SPMS with new brain lesions” where applicable).

Supplemental background: the purpose of this form is to collect required patient identifiers (all items marked with an asterisk), prescriber and office information, the specific medication requested (including dose, quantity, duration, J-code, frequency, and ICD-10 diagnosis), and whether the request is a new start or continuation. It captures prior therapy details (dates, failures, intolerances, contraindications), site-of-care and pharmacy sourcing (for example Accredo, retail, hospital outpatient, physician office, home infusion), administration site, and clinical rationale to support medical necessity and utilization management.

The form also includes specific questions for continuation requests (previous approvals, duration of regular use, restart after break) and additional attestations for certain agents (for example, items related to highly-active disease, MRI findings, cognitive impairment, and neurologist involvement when requesting Lemtrada or Tysabri). Completed and signed prescriber attestation and required fields are necessary for Cigna to process and respond to the request.

Aubagio	Teriflunomide oral MS therapy (listed as requestable)
Avonex	Interferon Beta-1a injectable
Bafiertam DR	Diroximel fumarate (delayed release) oral
Betaseron	Interferon Beta-1b injectable
Copaxone	Glatiramer acetate
Extavia	Interferon Beta-1b injectable
Gilenya	Fingolimod oral
glatiramer (Mylan)	Glatiramer product
Glatopa	Glatiramer (Sandoz)
Kesimpta	Ofatumumab subcutaneous

OpenPayer

Multiple Sclerosis: Aubagio, Avonex, Bafiertam DR, Betaseron, Copaxone, Extavia, Gilenya, Glatiramer, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus

Coverage Summary

Form: Required Clinical and Administrative Criteria

Actions for Providers / Submission Instructions

Drugs / Billing Notes Listed on Form

Definitions and Background

Revision History