CurrentCignaPolicy N/A

prior_authorization_request_form_besponsa

A payer prior-authorization request form to collect patient, prescriber, clinical, and dispensing information for coverage review of Besponsa (inotuzumab ozogamicin), including urgency, diagnosis, clinical details, site of administration, and pharmacy source.

Policy Summary

PayerCigna

Policyprior_authorization_request_form_besponsa

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; ensure all asterisked items are completed because Cigna will not respond via fax unless they are.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Medication covered by form

5Key required clinical fields

Besponsa PA Request Form — Purpose & Key Fields

This is a Cigna prior authorization request form for Besponsa (inotuzumab ozogamicin) used to collect the information needed to determine coverage and process authorization requests. The form asks for patient and prescriber identification, clinical diagnosis and disease characteristics (including relapsed/refractory status and CD22 status), therapy details (dose, quantity, duration, frequency), site of care, and dispensing source.

The form is informational and intended to support payer review and authorization determinations; it collects required data such as J-code, ICD-10 and CPT/procedure codes, facility and dispensing details, and prescriber attestation/signature to enable processing.

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Form completion and triage criteria required for review

Form completion and clinical data required for PA review

Authorization will be considered when the form is completed and clinical questions answered:

ALL of the following

Patient identification fields completed (Patient Name, Cigna ID, Date of Birth, Patient Street Address, Patient Phone)
Prescriber identification fields completed (Physician Name, Specialty, DEA/NPI or TIN, Office Contact Person, Office Phone, Office Fax, Office Street Address)
Medication requested specified (Besponsa 0.9mg vial) with dose, quantity, duration, frequency, and J-code provided
Diagnosis indicated: Diagnosis/reason for treatment indicated (B-cell precursor acute lymphoblastic leukemia (ALL) or Other)
Relapsed or refractory status provided: Clinical information provided including whether disease is relapsed or refractory
CD22-positive status indicated: CD22-positive disease status indicated (Yes/No)
Additional pertinent information provided (disease stage, prior therapy, performance status, concurrent agents with names/doses/schedules)
Site of medication acquisition indicated (Accredo Specialty Pharmacy, Physician's office stock, Home Health/Home Infusion vendor)
Facility and/or doctor dispensing identified: Facility and/or doctor dispensing and administering medication identified (facility name, state, tax ID, address)
Attestation and prescriber signature with date

Urgency determination

Select urgency and attest if urgent:

ANY of the following

Standard
Urgent (attestation that applying standard timeframe may seriously jeopardize life, health, or ability to regain maximum function)

Chronic/long-term therapy indication

ANY of the following

Chronic - Yes: Is the requested medication for a chronic or long-term condition for which medication may be necessary for the life of the patient? Yes
Chronic - No: Is the requested medication for a chronic or long-term condition for which medication may be necessary for the life of the patient? No

Requested coding fields on the form

Requested medication codingHCPCS

J-code

J-code (to be provided on form for Besponsa)

Diagnosis coding requestedICD-10

ICD10

ICD-10 code(s) to be provided on form (e.g., B-cell precursor acute lymphoblastic leukemia)

Procedure coding requestedCPT

CPT Code(s)

CPT code(s) for infusion/administration to be provided on form

The form requests the medication J-code and ICD-10 diagnosis code(s), and also captures CPT code(s) for infusion/administration. Facility tax ID and the dispensing source (e.g., Accredo Specialty Pharmacy, physician office stock, or home infusion vendor) are collected to support billing and claims processing.

Submission, documentation, and billing requirements

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. Ensure all asterisked (*) items on the form are completed — Cigna will not respond via fax unless those items are filled out.

Prior Authorization

Urgent requests require phone call

For urgent requests, call (800) 882-4462 to expedite. Standard response time for prescription drug coverage requests is 5 business days.

Documentation Required

Provide clinical documentation

Provide clinical documentation to support medical necessity, including: diagnosis, whether disease is relapsed or refractory, CD22-positivity status, prior therapies, performance status, and any concurrent medications including names, doses, and administration schedules.

Diagnosis
Relapsed or refractory status
CD22-positive disease status
Prior therapies
Performance status
Concurrent medications with names, doses, and schedules

Billing Rule

Specify dispensing site and billing codes

Indicate where the medication will be obtained (Accredo Specialty Pharmacy, physician's office stock, or Home Health/Home Infusion vendor) and provide facility and/or doctor dispensing information (facility name, state, tax ID, address). Include CPT and HCPCS/J-code(s) for administration on the form.

Medication acquisition source (Accredo, physician office stock, Home Health/Home Infusion)
Facility/doctor dispensing details (name, state, tax ID, address)
CPT Code(s) and J-code/HCPCS for administration