CurrentCignaPolicy N/A

Aliqopa (copanlisib) prior authorization form

Prior authorization form and requirements for coverage of Aliqopa (copanlisib) vials for Cigna members; directed to prescribing providers seeking medical benefit coverage (infusion/office/hospital/home infusion) for oncology indications.

Policy Summary

PayerCigna

PolicyAliqopa (copanlisib) prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization 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 or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

2+prior systemic therapies question (at least 2 prior systemic therapies)

60 mgAliqopa vial strength listed as option

urgency optionStandard or Urgent request selection

Coverage Criteria

Form completion criteria

Coverage support requires completion of all of the following form items:

Basic administrative information: Completed prescriber and patient identifiers including all asterisked fields (physician name, DEA/NPI/TIN, Cigna ID, DOB, addresses)

See patient information section on form

Medication request details: Specify urgency (standard or urgent), medication (Aliqopa 60mg vial), ICD-10 code, dose, quantity, frequency, and duration of therapy

See medication requested and urgency fields

Diagnosis selection: Select one diagnosis from the form options (follicular lymphoma, gastric MALT lymphoma, nongastric MALT lymphoma, nodal marginal zone lymphoma, or other) and provide specification if 'other' is selected

See diagnosis checklist on form

Policy Summary

PayerCigna

PolicyAliqopa (copanlisib) prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and fax the prior authorization 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

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Prior therapy and disease status: Indicate whether disease is relapsed or refractory and whether the patient has previously received at least 2 prior systemic therapies for this diagnosis

See clinical information questions

Clinical details: Provide additional pertinent information including disease stage, prior therapy details, performance status, and names/doses/administration schedule of any concurrent agents

See additional pertinent information field

Attestation and signature: Prescriber attestation that information is true and accurate and prescriber signature with date

See attestation and signature lines

The form collects site-of-care information — including whether the medication will be dispensed/administrated by the facility or doctor (facility name, state, Tax ID, address), whether the patient is a candidate for home infusion, and whether the physician has an in-office infusion site. These items are used to determine billing pathway and logistics (medical benefit/office stock vs home infusion vendor) but the form does not list any explicit site-of-care exclusions or prohibit a specific setting.

The form does not spell out discrete scenarios that would be deemed Not Medically Necessary. Instead, it requests clinical justification items (relapsed/refractory status, prior therapies, disease stage, performance status, and concurrent agents) that must be supplied to support medical necessity. In practice, failure to provide required clinical details or to attest to prior therapies (for example, not documenting relapsed/refractory disease or prior systemic treatments) could lead to a determination of not medically necessary or result in denial under the plan’s standard review processes.

Requested Medication / Coding

Requested medicationNDC | mixed

Aliqopa 60mg vial

Medication strength/packaging option listed on form

Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization and Submission

Prior authorization is required. Fax completed form to: (855) 840-1678. If this is an URGENT request, call (800) 882-4462 (800.88.CIGNA). Save time! Submit online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Fax: (855) 840-1678
Urgent phone: (800) 882-4462 (800.88.CIGNA)
Online submission: www.covermymeds.com/main/prior-authorization-forms/cigna/
SureScripts via EHR

Documentation Required

Required Form Fields and Clinical Details

Complete all required patient and prescriber fields. Due to privacy regulations Cigna will not respond via fax with the outcome unless all asterisked (*) items are completed.

Patient Name*
Cigna ID*
Date of Birth*
Patient Street Address*
Physician Name*
Specialty
DEA, NPI or TIN*
Office Contact Person
Office Phone
Office Fax
Office Street Address
City / State / Zip (patient and office)
Patient Phone

Denial Risk

Prior Therapy Verification & Clinical Requirements

Provide clinical information including disease status and prior therapies. Failure to attest to prior therapies or provide required clinical information may delay or result in denial of the request.

Does the patient have relapsed or refractory disease? (Yes/No)
Has the patient previously received at least 2 prior systemic therapies for this diagnosis? (Yes/No)
Medication requested (e.g., Aliqopa 60mg vial), ICD-10, dose and quantity, frequency and duration of therapy
Additional pertinent information: disease stage, prior therapy details (names/doses/schedule), performance status, concurrent agents
Attestation: Prescriber signature and date required

Note

Incomplete Information May Delay or Deny Request

Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, call the number above to expedite. The Health Plan or its designees may audit and request medical records to verify the information on this form.

Standard response time: 5 business days
Urgent requests: call (800) 882-4462
Audits: medical record verification may be requested

Initial Therapy Criteria

Initial therapy justification

Initial authorization is supported when ALL of the following are documented on the form:

Relapsed/refractory status: Provider must indicate whether the patient’s disease is relapsed or refractory (Yes or No)

See Clinical Information section

Prior systemic therapies: Provider must indicate whether the patient has received at least 2 prior systemic therapies for this diagnosis (Yes or No)

This item is required to justify use

Step Therapy / Prior Treatments

Step	Requirement
1
Document whether the patient has relapsed or refractory disease (Yes/No) on the clinical information section of the form.
2
Indicate whether the patient has previously received at least 2 prior systemic therapies for this diagnosis (Yes/No) on the form.
3
Provide additional pertinent clinical information: disease stage, details of prior therapies, performance status, and names/doses/administration schedule of any concurrent agents.

Site of Care

Note

Document site of care: home, office, or infusion center

Indicate where the medication will be obtained on the form (prescriber's office stock, home health/home infusion vendor, or other) and answer whether the patient is a candidate for home infusion and whether the physician has an in‑office infusion site; this information informs site-of-care billing and administration.

Where will this medication be obtained? (Prescriber's office stock / Home Health / Other)
Is the patient a candidate for home infusion? (Yes/No)
Does the physician have an in‑office infusion site? (Yes/No)

Definitions / Selectable Diagnoses

Diagnoses listed

Follicular lymphoma (FL)Selectable diagnosis option on the form

Gastric MALT lymphomaSelectable diagnosis option on the form

Nongastric MALT lymphomaSelectable diagnosis option on the form

Nodal marginal zone lymphoma (NMZL)Selectable diagnosis option on the form

Other (please specify)Free-text option for diagnoses not listed

Background

Aliqopa (copanlisib) is an intravenous oncology agent for select lymphomas; the form captures diagnosis selection (options include follicular lymphoma (FL), gastric or nongastric MALT lymphoma, nodal marginal zone lymphoma (NMZL), or other) and asks for clinical details to justify use. The clinical section specifically asks whether the patient has relapsed or refractory disease and whether the patient previously received at least 2 prior systemic therapies, plus additional pertinent information (disease stage, prior therapy, performance status, and names/doses/schedule of concurrent agents) to support the authorization request.