CurrentCignaPolicy N/A

Poteligeo (mogamulizumab-kpkc) prior authorization form

This document is a Cigna prior authorization request form for the specialty drug Poteligeo (mogamulizumab-kpkc), used to request coverage and provide clinical information for patients with mycosis fungoides, Sézary syndrome, or adult T-cell leukemia/lymphoma. It is intended for prescribers and infusion providers submitting authorization to Cigna Pharmacy Services.

Policy Summary

PayerCigna

PolicyPoteligeo (mogamulizumab-kpkc) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including patient and prescriber identifiers, diagnosis and ICD-10 code, prior therapy history, dosing, and prescriber signature to support coverage determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

(855) 840-1678fax

(800) 882-4462urgent phone

v102622form version

Coverage Criteria and Required Information

Information required for medical necessity review

Information requested to support coverage determination (to be evaluated by Cigna):

Clinical data required: Patient diagnosis (MF/SS or ATLL or other) AND for MF/SS: relapsed or refractory status AND prior receipt of at least one prior systemic therapy; for ATLL: prior treatments, response to first-line therapy, ATLL subtype, and whether Poteligeo will be used as single-agent therapy.

Providers must attest and supply prior therapy details, performance status, and concurrent agents.

The form asks whether the requested medication is for a chronic or long-term condition and specifically whether the prescription may be necessary for the life of the patient. Providers should complete this field to inform the Health Plan’s medical necessity review and site-of-care planning.

The form does not list specific conditions under which therapy would be considered not medically necessary. Instead, it requires submission of clinical information and an attestation so that the Health Plan or its designees can review the documentation and make coverage determinations based on the information provided.

Diagnosis and Billing Codes

Policy Summary

PayerCigna

PolicyPoteligeo (mogamulizumab-kpkc) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Diagnosis code fieldICD-10

ICD10

ICD-10 diagnosis code (field provided on form)

Provider Actions, Documentation, and Submission

Prior Authorization

Prior Authorization Required

Poteligeo (mogamulizumab-kpkc) prior authorization is required. Complete and submit all required documentation; missing required fields (marked with *) may prevent a fax response and delay processing.

Medication requested: Poteligeo
Submit via CoverMyMeds or SureScripts (preferred) or fax (ensure all * items completed)
Standard response time: 5 business days; call to expedite urgent requests

Documentation Required

Required Documentation

Provide complete patient and prescriber identifiers and diagnosis information. All items marked with an asterisk (*) on the form must be completed to avoid processing delays. Required documentation includes:

Patient identifiers: full name, Cigna ID, date of birth, address, phone
Prescriber identifiers: physician name, specialty, DEA, NPI or TIN, office contact, phone, fax, office address
Diagnosis and ICD-10 code
Medication requested details: dose, frequency, duration, start date, current weight
Attestation and prescriber signature/date

Documentation Required

Line-of-Therapy Documentation

Document prior therapy and line-of-therapy status for the relevant diagnosis. For MF/SS and ATLL, complete the MF/SS- and ATLL-specific fields on the form to show relapsed/refractory status and prior systemic treatments.

(If MF/SS) Indicate whether disease is relapsed or refractory
(If MF/SS) Confirm patient has received at least one prior systemic therapy for this diagnosis (Yes/No)
(If ATLL) Indicate prior treatments and whether patient did not respond to first-line therapy
(If ATLL) Specify ATLL subtype (acute, chronic, lymphoma, smoldering, unknown)
List prior therapies, disease stage, performance status, and names/doses/schedules of concurrent agents

Denial Risk

Incomplete Form Risk / Submission Notes

Incomplete forms or missing required fields may prevent our ability to respond via fax and will delay review and processing. Ensure all asterisked (*) items are completed and include supporting clinical information to avoid denials or delays.

If urgent, check 'Urgent' and call to attest that standard time frame may jeopardize patient
Save time by submitting online at CoverMyMeds or via SureScripts in the EHR

Initial Therapy Information

Initial therapy details — information requested to support authorization

Initial therapy information requested to support authorization:

Initial therapy items: Indicate if this is a new start, start date, dose, frequency, duration, and current weight; for MF/SS indicate relapsed/refractory and prior systemic therapy history; for ATLL indicate prior treatments and response to first-line therapy.

Form includes checkbox for 'Is this a new start?' and fields for start date and dosing.

Continuation Therapy and Administration Details

Administration and site-of-care information — continuation/administration details for ongoing approvals

Continuation/administration details collected to support ongoing therapy approvals and site-of-care considerations:

Site and supply: Indicate where medication will be obtained (CVS Caremark, prescriber's office stock, home infusion vendor, or other) and whether patient is candidate for home infusion or if physician has in-office infusion site.

Facility name, tax ID, and address fields provided for dispensing/administration site.

Prior Therapy and Step Requirements

Documentation requested	Details captured on form
Relapsed or refractory disease (for MF/SS)	Checkbox: Yes / No
Prior receipt of at least one prior systemic therapy (for MF/SS)	Checkbox: Yes / No
Prior treatments for ATLL	Checkbox: Yes / No; if yes, indicate whether patient did NOT respond to first-line therapy (Yes / No)
ATLL subtype	Checkboxes: acute / chronic / lymphoma / smoldering / unknown
Whether Poteligeo will be used as single-agent therapy (for ATLL)	Checkbox: Yes / No

Sourcing and Site-of-Care Selection

Note

Choose medication source and site-of-care

Select where the medication will be obtained and indicate whether the patient is a candidate for home infusion or if the physician has an in-office infusion site.

Sourcing options: CVS Caremark, prescriber's office stock, home infusion vendor, or other (chunk 3)
Site-of-care details: facility name, tax ID, address; home infusion candidacy and in-office infusion availability (chunk 4)

Key Terms and Drug Name

Poteligeo — key term

Drug name (brand & generic)Poteligeo (mogamulizumab-kpkc)

Drug classMonoclonal antibody; oncology; specialty biologic

Form usePrior authorization request form for Poteligeo

Diagnoses — form options

Diagnoses listed on formmycosis fungoides (MF)/Sézary syndrome (SS)

Diagnoses listed on formadult T‑cell leukemia/lymphoma (ATLL)

Other optionOther (please specify) — free-text field on form

ATLL subtype optionsacute; chronic; lymphoma; smoldering; unknown

Background

Poteligeo (mogamulizumab-kpkc) is a specialty monoclonal antibody indicated for certain cutaneous T‑cell lymphomas. The prior authorization form collects the patient diagnosis (options include mycosis fungoides (MF)/Sézary syndrome (SS) and adult T‑cell leukemia/lymphoma (ATLL)), prior therapy history, disease stage, performance status, and names/doses/schedule of concurrent agents to support medical necessity review.