CurrentCignaPolicy N/A

Prior Authorization Form for Elahere (mirvetuximab)

A Cigna prior authorization request form to collect required clinical, demographic, dispensing, and administration information to evaluate coverage for Elahere (mirvetuximab). It specifies required documentation, urgency options, intended site of dispensing/administration, diagnosis options, and clinical questions to support approval.

Policy Summary

PayerCigna

PolicyPrior Authorization Form for Elahere (mirvetuximab)

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionFax the completed form and all supportive documentation to (855) 840-1678 or submit online via CoverMyMeds / SureScripts; supportive documentation required for ALL answers.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes identified.

1Form Version (v010124)

3Primary selectable cancer diagnoses listed

6Required patient/prescriber data elements marked with *

Policy summary

This is Cigna Pharmacy Services' prior authorization form to collect the information needed to adjudicate coverage for Elahere (mirvetuximab). The form asks for patient and prescriber identifiers (physician name, DEA/NPI/TIN, patient name, Cigna ID, date of birth, patient street address) and requires completion of all asterisked items before Cigna will respond via fax.

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When this form applies

This form is intended to evaluate coverage for Elahere by collecting clinical, demographic, and dispensing/administration information necessary for medical review. It requires specification of the medication requested, ICD-10 diagnosis code(s), directions for use, and duration of therapy.

Required information includes patient and prescriber identifiers, the patient's diagnosis (selectable ovarian, fallopian tube, or primary peritoneal cancer), FR-alpha positive disease status, prior platinum therapy and platinum-resistance, and the number of prior systemic regimens. The form also asks where the medication will be obtained and where it will be administered.

The form specifies that supportive documentation is required for ALL answers (chart notes, lab/test results, etc.), provides an option to mark the request as Standard or Urgent (with an attestation for Urgent requests), and gives submission instructions (fax or online) and a phone number to call for urgent requests.

ICD-10 diagnoses (form selectable)ICD-10

	epithelial ovarian cancer (selectable; specific ICD-10 not provided on form)
	fallopian tube cancer (selectable; specific ICD-10 not provided on form)
	primary peritoneal cancer (selectable; specific ICD-10 not provided on form)

Required form completion & provider actions

Required form completion and documentation

Prior authorization request will require completion of all asterisked items and supportive documentation:

ALL of the following

Complete all asterisked patient and prescriber items: All asterisked (*) patient and prescriber items on the form must be completed (physician name, DEA/NPI/TIN, patient name, Cigna ID, Date of Birth, patient street address).
Due to privacy regulations Cigna will not respond via fax unless all asterisked (*) items are completed.
Attach supportive documentation for ALL answers, including chart notes, lab/test results; if online, attach supportive documentation with the request.
Medication requires supportive documentation for all answers.
Indicate urgency and attest if urgent: Indicate urgency: Standard or Urgent. If Urgent, prescriber attests that applying standard review time frame may seriously jeopardize patient's life, health, or ability to regain maximum function.
Urgent requests should also be called to expedite review.
Specify medication, diagnosis code(s), directions and duration: Specify medication requested (Elahere 100 mg/20 mL vial or other specified), ICD-10 diagnosis code(s), directions for use, and duration of therapy.
Indicate where medication will be obtained (Accredo Specialty Pharmacy, Hospital Outpatient, Retail, Home Health/Home Infusion, Physician's office stock, Other).
Accredo is Cigna's nationally preferred specialty pharmacy and ordering/contact details provided.
Indicate where drug will be administered (Patient's Home, Physician's Office, Hospital Outpatient, Other).
Chronic therapy question: Indicate whether medication is for a chronic/long-term condition that may be necessary for the life of the patient (Yes/No).
Select diagnosis: epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer, or other (specify).
Document FR-alpha status: Document FR-alpha positive disease status (Yes/No).
Document prior platinum therapy and platinum-resistance: Document whether patient was previously treated with carboplatin or cisplatin (platinum therapy) and whether disease is platinum-resistant (Yes/No).
Number of prior systemic regimens: State number of systemic treatment regimens patient has already received for this cancer (0,1,2,3,4+).
Provide additional clinical support including disease stage, prior therapy, performance status, and names/doses/admin schedule of any agents to be used concurrently.
Prescriber signature and date required attesting truthfulness and permitting audit.

Prior Authorization

Submit completed prior authorization form and documentation

Fax the completed form and all supportive documentation to (855) 840-1678 or submit online via CoverMyMeds / SureScripts. Supportive documentation is required for ALL answers.

Fax: (855) 840-1678
Online: CoverMyMeds / SureScripts

Prior Authorization

Urgent requests must be called

If the request is marked Urgent, the prescriber must call (800) 882-4462 in addition to faxing/submitting the completed form to expedite review and must attest to the urgency criteria.

Documentation Required

Required clinical documentation

Required supporting documentation includes chart notes, lab/test results, disease stage, prior therapies, performance status, and names/doses/schedules of any agents to be used concurrently.

Chart notes
Lab/test results
Disease stage
Prior therapies
Performance status
Names, doses, and administration schedules of concurrent agents

Billing Rule

Preferred specialty pharmacy

Accredo is Cigna's nationally preferred specialty pharmacy. Medication orders can be placed with Accredo via e-prescribe, fax, or verbally using the contact details provided.

E-prescribe: Accredo (NCPDP 4436920)
Fax: 888.302.1028
Verbal: 866.759.1557

OpenPayer

Prior Authorization Form for Elahere (mirvetuximab)

Policy summary

When this form applies

Required form completion & provider actions

Definitions

Document history