CurrentCignaPolicy N/A

prior_authorization_form_ankiva

A prior authorization form used by Cigna to request coverage review for the medication Anktiva (nogapendekin alfa inbakicept-pmln), capturing patient, prescriber, clinical, and dispensing site information required to process a PA for NMIBC (non-muscle invasive bladder cancer) and related uses.

Policy Summary

PayerCigna

Policyprior_authorization_form_ankiva

Policy CodePolicy N/A

Change TypeInformational (form)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts and include all required asterisked fields and supportive documentation to enable review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

FormDocument Type

AnktivaMedication

NMIBCPrimary Indication Captured

Policy overview and purpose

This prior authorization form is used to request coverage review for Anktiva (nogapendekin alfa inbakicept-pmln) and collects the clinical, administrative, and billing information necessary to process a coverage determination for non‑muscle invasive bladder cancer (NMIBC) and related uses. The form requires completion of key patient and prescriber identifiers, medication details (including J‑Code and ICD‑10), the selected dispensing site, and clinical responses about prior therapies and tumor characteristics. Supportive documentation (for example, genetic testing, chart notes, and lab/test results) must be attached to enable review, and prescriber attestation and signature with date are required. Fax and phone submission instructions are provided for standard and urgent requests.

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Form-required clinical affirmations and selections

Provider must complete all asterisked items and attach supportive documentation; selections capture diagnosis and prior therapy status:

ALL of the following

Patient identifiers and contact information completed for all asterisked (*) items (Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address).
Form will not be responded to via fax unless asterisked items are completed.
Urgency selection: Indicate urgency: Standard or Urgent (attestation required for Urgent).
Medication formulation and dosing fields: Select requested medication formulation: Anktiva 400 mcg/0.4 mL vial; provide directions for use, dose and quantity, duration of therapy, J-Code, and ICD10.
Dispensing site selection: Select dispensing site: Accredo Specialty Pharmacy, Hospital Outpatient, Retail pharmacy, Home Health/Home Infusion, Physician's office stock, or Other (specify).
Accredo is Cigna's nationally preferred specialty pharmacy; medication orders can be placed with Accredo via e-prescribe, fax, or verbal as listed.
Diagnosis related to use (select one or more)
- NMIBC: non-muscle invasive bladder cancer (NMIBC)
- Other (provider must specify)
If NMIBC selected, provider must answer:
- CIS status: Does the patient have NMIBC with carcinoma in situ (CIS)? (Yes/No)
- BCG response
  - BCG yes: Yes
  - BCG no response: No response to treatment
  - BCG not tried: Did not try BCG
    If not tried, please explain why BCG was not tried.
- Papillary tumors:
Supportive documentation: Attach supportive documentation (genetic testing, chart notes, lab/test results) for the drug request.
Supportive documentation for all answers must be attached with this request. Failure to attach required documentation may prevent response.
Provider attestation and signature required, with date.

ref

Billing and diagnosis codes to provide

Form fields for billing and diagnosis codes to be provided by requestermixed

J-Code	Requestor must supply applicable J-code for the medication on the form
ICD10	Requestor must supply applicable ICD-10 code for diagnosis

Billing Rule

Specialty pharmacy preference

Accredo is Cigna's nationally preferred specialty pharmacy. Orders to Accredo may be placed via e-prescribe, by fax, or verbally using the contact methods listed on the form. Use Accredo for dispensing when preferred and select it on the form as the dispensing site.

Accredo is Cigna's nationally preferred specialty pharmacy.
Ordering options: e-prescribe, Fax (888.302.1028), Verbal (866.759.1557).
Select Accredo Specialty Pharmacy on the form when it is the dispensing site.

What providers must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. Include all required asterisked fields and attach all supportive documentation requested on the form to enable review.

Fax completed form to: (855) 840-1678.
Submit online at CoverMyMeds or via SureScripts in your EHR.
Complete all asterisked (*) items on the form and attach required supportive documentation.

Prior Authorization

Urgent request protocol

For urgent requests, check the Urgent box on the form and attest that applying the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function. In addition to submitting the form, call (800) 882-4462 to expedite the request.

Check the Urgent box and include the required attestation.
Call (800) 882-4462 in addition to submitting the form to expedite review.

Documentation Required

Supportive documentation required

Attach all required supportive documentation with the request, including genetic testing, chart notes, and lab/test results. If BCG was not tried, provide an explanation on the form. The form states that supportive documentation for all answers must be attached and notes that failure to attach required documentation may prevent a response.

Required attachments: genetic testing, chart notes, lab/test results.
If BCG was not tried, explain why on the form.
Supportive documentation for all answers must be attached; failure to attach required documentation may prevent response.

Definitions

AccredoCigna's nationally preferred specialty pharmacy; contact/order: E-prescribe via Accredo (1620 Century Center Pkwy, Memphis, TN 38134-8822 | NCPDP 4436920), Fax 888.302.1028, Verbal 866.759.1557

The form captures patient, prescriber, clinical, and dispensing site information needed to process a prior authorization for Anktiva for NMIBC, including: asterisked patient and physician identifiers (Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address); medication selection and dosing details (Anktiva 400 mcg/0.4 mL vial, directions, dose/quantity, duration, J‑Code, ICD10); choice of dispensing site (including Accredo Specialty Pharmacy as Cigna’s nationally preferred specialty pharmacy); clinical questions about NMIBC/CIS, BCG treatment history, papillary tumors, and combination use with BCG; and an attestation/signature block. Urgent requests require calling the listed phone number in addition to form submission.