CurrentCignaPolicy N/A

prior_authorization_form_tivdak

This document is a Cigna prior authorization request form to be completed by prescribers to request coverage/authorization for Tivdak (tisotumab vedotin-tftv), capturing patient, prescriber, clinical, dispensing, and treatment details needed for review.

Policy Summary

PayerCigna

Policyprior_authorization_form_tivdak

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this prior authorization form.

1Form pages / core document

5Business days standard response time

Policy summary and purpose

This is Cigna's prior authorization request form to be completed by prescribers to request coverage/authorization for Tivdak (tisotumab vedotin-tftv). It is designed to capture patient, prescriber, clinical, dispensing, and treatment details needed for review, including diagnosis and disease-specific clinical information, medication requested and administration details, and facility/dispensing billing information. The form identifies Cigna's nationally preferred specialty pharmacy as Accredo and provides ordering/contact options for Accredo. Completed forms may be faxed to (855) 840-1678, and submissions can also be made online via CoverMyMeds or SureScripts; urgent requests should be called to (800) 882-4462 for expedited review.

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Required fields and form completion

Form completion / information required

Authorization will be reviewed when all required fields (asterisked) and clinical information are provided:

ALL of the following

Physician Name (required if asterisked)
Specialty
DEA, NPI or TIN (required if asterisked)
Office Contact Person
Patient Name (required if asterisked)
Cigna ID (required if asterisked)
Date of Birth (required if asterisked)
Patient Street Address (required if asterisked)
Diagnosis selection: cervical cancer, vaginal cancer, or other (specify)
If cervical cancer selected
- Recurrent or metastatic disease? (Yes/No)
- Is this the first chemotherapy for this diagnosis? (Yes/No)
- If not first, has disease progressed on or after previous chemotherapy? (Yes/No)
If vaginal cancer selected
- Will this medication be the only cancer drug used for this diagnosis? (Yes/No)
- Will/Is this medication used as second-line or subsequent therapy? (Yes/No)
- Does patient have locoregional recurrence, recurrent distant metastases, OR stage IVB disease? (Yes/No)
Medication Requested: Tivdak 40mg vial (checkbox)
Directions for use, Quantity, Frequency of Therapy, Duration of therapy, J-Code
Is this a new start? (Yes/No) and Start date
ICD-10 code(s)
Will this medication be given concurrently with other agents? (Yes/No); if yes, specify agents
Patient weight
Where will medication be obtained? (Accredo Specialty Pharmacy, prescriber office stock, retail, home infusion, other)
Facility and/or doctor dispensing and administering medication details (name, tax ID, address)
Home infusion candidacy and in-office infusion site availability (Yes/No)
Is the medication for a chronic/long-term condition for which prescription medication may be necessary for life of patient? (Yes/No)
Additional pertinent information: disease stage, prior therapy, performance status, names/doses/admin schedule of concurrent agents
Prescriber attestation and signature with date

Authorization will be reviewed when all required (asterisked) fields and clinical information are provided. Typical required items on the form include: Physician name, DEA, NPI or TIN, Patient name, Cigna ID, Date of birth, and Patient street address. The form also requires prescriber attestation plus a prescriber signature and date.

Urgency, response expectations, and submission routes

Urgency and response expectations

ALL of the following

Urgency checkbox: Standard or Urgent (urgent attestation required)
Standard response time for prescription drug coverage requests is 5 business days; urgent requests should be called to expedite

Prior Authorization

Urgent request protocol

If this is an urgent request, check the Urgent box on the form and call (800) 882-4462 to attest that applying the standard review time frame may seriously jeopardize the patient’s life, health, or ability to regain maximum function. Calling will expedite the review.

Prior Authorization

Submit completed prior authorization form

Fax the completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. Be sure to include all required (asterisked) fields and the clinical details requested so the authorization can be reviewed.

What providers must submit and document

Documentation Required

Provide disease- and therapy-specific clinical details

Include disease- and therapy-specific clinical details to support medical necessity.

Diagnosis
Disease stage
Prior therapies
Response or progression on prior chemotherapy (if applicable)
Performance status
Concurrent agents and administration schedule

Billing Rule

Specify source and billing route for medication

Indicate where the medication will be obtained and the billing route; provide facility/dispensing details if applicable.

Specify source: Accredo specialty pharmacy, prescriber office stock (billing on a medical claim), retail pharmacy, or home infusion
If billing from a facility or prescriber's office, provide facility name, address, and Tax ID