CurrentCignaPolicy N/A

Praluent Prior Authorization Form

Prior authorization form used by Cigna for requests to initiate or continue Praluent (alirocumab), collecting patient, prescriber, diagnosis, prior therapy, and clinical documentation to support coverage decisions. It instructs where medication will be obtained and includes attestations and contact/fax numbers for submission.

Policy Summary

PayerCigna

PolicyPraluent Prior Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form (including all asterisked items) to (855) 840-1678 or submit online at covermymeds.com; incomplete forms delay processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Product strengths listed

3Primary indication categories listed

3Required statin/therapy documentation items

Summary and scope

This is Cigna's prior authorization form for Praluent (alirocumab) used to collect the clinical and administrative information necessary to evaluate coverage requests. The form requests patient and prescriber identifying information, the specific Praluent product selection (Praluent 75mg or Praluent 150mg), ICD-10 diagnosis, directions/quantity, duration of therapy, and where the medication will be obtained (for example, Accredo Specialty Pharmacy, prescriber office stock, retail, home infusion, or other). Submission instructions include faxing the completed form to (855) 840-1678, submitting online via CoverMyMeds, and calling (800) 882-4462 for urgent requests.

The form notes that Cigna's nationally preferred PCSK9 product is Repatha (evolocumab) and therefore asks whether the patient has tried Repatha or is a candidate for it, and requests supportive documentation. It also collects required clinical details such as prior lipid-lowering therapies, documentation of statin intolerance or contraindication, LDL-C values and duration of prior regimens (including maintenance on therapy for at least 12 consecutive weeks), and disposition options for dispensing and prescriber attestation/signature.

Key thresholds and quick facts

LDL-C threshold before adding Praluent> 70 mg/dL

HeFH diagnostic LDL-C threshold (prior to treatment)>= 190 mg/dL

Required duration on statin regimen before assessing LDL-C>= 12 consecutive weeks

Available Praluent product strengths on formPraluent 75mg; Praluent 150mg

Primary indication categories listed on formhyperlipidemia with ASCVD; primary hyperlipidemia (including HeFH); hyperlipidemia without ASCVD or FH

Authorization information and required clinical documentation

Form collects required information; approvals are contingent on meeting plan clinical criteria (implied).

Patient and prescriber identifying information must be completed for response to be returned (all asterisked items).

Refer to form asterisked fields for required items

Medication selection: Specify medication requested (Praluent 75mg or Praluent 150mg).

From medication requested options on form

Diagnosis code: Provide ICD-10 diagnosis code.

ICD10 selection options available on form

Therapy duration and quantity: Indicate duration of therapy, directions for use and quantity.

Fields for directions, quantity, and duration on form

Dispensing location: Indicate where medication will be obtained (Accredo Specialty Pharmacy, prescriber office stock billing on medical claim, retail pharmacy, home health/home infusion vendor, other).

Accredo is Cigna's nationally preferred specialty pharmacy

Chronic therapy flag: Specify whether medication is for chronic/long-term condition requiring lifelong therapy (Yes/No).

Form asks if medication is for chronic or long-term condition

Diagnosis selection (one of)

ASCVD category: hyperlipidemia WITH atherosclerotic cardiovascular disease (ASCVD)
Form option
Primary hyperlipidemia: primary hyperlipidemia [including heterozygous familial hypercholesterolemia (HeFH)]
Form option
No ASCVD/FH: hyperlipidemia WITHOUT either ASCVD or FH
Form option
Other diagnosis: other (please specify)
Form option

New vs continuation of therapy

Continuation: documented benefit: If continuation and prior therapy exists, indicate documented clinical benefit (e.g., LDL-C reduction) or provide clinical support if no documented benefit.
Form asks if documented evidence of clinical beneficial response exists
Prior Repatha use: Indicate whether patient tried Repatha (evolocumab) in past; if yes, provide documented response; if no, indicate if patient is candidate for Repatha and provide rationale if not.
Cigna's preferred product is Repatha; supportive documentation required

Concurrency with evolocumab/lomitapide: Indicate whether Praluent will be used concurrently with evolocumab (Repatha) or in combination with lomitapide (Juxtapid).

Form asks about concurrent use

Additional pertinent information: Provide additional pertinent information including disease stage, prior therapy, performance status, and names/doses/admin schedule of concurrent agents.

Free-text field on form

Prescriber attestation and signature with date required.

Form includes attestation and signature/date fields

Codes and product selection captured on form

Medication product selectionmixed

Praluent 75mg	Selected product strength option on form
Praluent 150mg	Selected product strength option on form

Diagnosis choices (ICD-10)ICD-10

ICD10

Placeholder: form requires ICD-10 diagnosis code for the indication (hyperlipidemia, HeFH, ASCVD, other)

What the prescriber must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form, including all asterisked items, to (855) 840-1678 or submit online via covermymeds.com; incomplete forms will delay processing.

Include all asterisked items

Prior Authorization

Urgent requests

For urgent requests, call (800) 882-4462 to expedite review in addition to faxing or submitting the completed form.

Documentation Required

Supportive documentation for prior therapy

Provide supportive documentation showing prior Repatha (evolocumab) use and documented response or, if not a candidate, the rationale and supporting documentation; also document statin intolerance or FDA-label contraindication and prior lipid-lowering therapies tried.

Documentation Required

Prescriber attestation and signature

The prescriber must attest that the information is true and accurate and sign and date the form; the health plan may perform audits and request medical records to verify accuracy.

Billing Rule

Specialty pharmacy preferred

Cigna's nationally preferred specialty pharmacy is Accredo; medication orders can be placed with Accredo via e-prescribe, fax, or verbally using the Accredo contact methods provided on the form.

Definitions

Maximally tolerated statin therapy: Not explicitly defined on the form but described as the highest intensity statin the patient can tolerate, with documentation of intolerance to higher intensity as applicable (the form asks that patients be treated with diet AND maximally tolerated statin therapy unless clinical support is provided).

Document changes and review dates