CurrentCignaPolicy v010124

Topotecan (Hycamtin) prior authorization form

This document is a Cigna prior authorization request form for intravenous topotecan (Hycamtin) and related topotecan products, to be completed by prescribers or their offices for coverage assessment and dispensing routing.

Policy Summary

PayerCigna

PolicyTopotecan (Hycamtin) prior authorization form

Policy CodePolicy v010124

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with full patient identifiers, medication details, ICD-10 diagnosis, and supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

800.882.4462phone for urgent requests

855.840.1678fax completed form to

Accredonationally preferred specialty pharmacy

v010124policy/document identifier

Coverage Considerations and Intake Indications

Policy Summary

PayerCigna

PolicyTopotecan (Hycamtin) prior authorization form

Policy CodePolicy v010124

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with full patient identifiers, medication details, ICD-10 diagnosis, and supporting clinical information.

SourceLink

On This Page

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Intake Indications

Coverage consideration is based on the submitted clinical information for one of the listed diagnoses and the requested treatment details.

Indications: Requested use must correspond to one of the listed diagnoses: bone cancer (including Ewing sarcoma, osteosarcoma); primary CNS lymphoma; cervical cancer; rhabdomyosarcoma; CNS brain metastases; small cell lung cancer (SCLC); leptomeningeal metastases; uterine neoplasm (endometrial carcinoma); Merkel cell carcinoma (MCC); ovarian, fallopian tube, or primary peritoneal cancer; or other specified diagnosis.

If CNS brain metastases is selected, provider should indicate primary tumor/site as requested on the form.

Supporting Clinical Details

Authorization reviewers will evaluate the following clinical details to determine medical necessity.

Supporting clinical details: Provide disease stage, prior therapy, performance status, and names/doses/administration schedule of any agents to be used concurrently.

If CNS brain metastases is selected, indicate whether small cell lung cancer (SCLC) is the primary tumor/site; if not, specify the primary tumor/site.

This prior authorization intake form does not list any explicit exclusions. Coverage consideration is driven by the clinical information submitted for the diagnoses and treatment details selected on the form; reviewers use the provided patient identifiers, diagnosis, treatment history, and supporting clinical data to determine whether requested use meets medical necessity.

The form does not enumerate specific conditions labeled "not medically necessary". Instead, denials would be determined by clinical review of the information submitted (for example, incomplete clinical justification, missing prior therapy details, or information inconsistent with accepted indications). Ensure the request includes the required clinical details so reviewers can assess medical necessity.

Initial Authorization Requirements

Initial authorization requires submission of key administrative and treatment-specific data to allow clinical review.

Initial request data: Submit ICD-10 diagnosis code, requested medication (exact product), proposed dose, frequency of therapy, and duration of therapy.

Include patient height and weight as requested on the form.

Clinical justification: Provide supporting clinical information including disease stage, prior therapies, performance status, and concurrent agents (names, doses, and administration schedule).

If CNS brain metastases is selected, indicate primary tumor/site per form instructions.

Administrative identifiers: Provide complete patient identifiers (Cigna ID, date of birth, address) and prescriber/facility information to avoid processing delays.

Incomplete patient or provider information may delay review or result in inability to respond via fax.

Provider Submission, Documentation, and Risk

Prior Authorization

Prior Authorization Required

Prior authorization required for IV Hycamtin (topotecan). Submit the completed form by fax or online; standard response time is 5 business days. If urgent, call to expedite.

Submit online: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.
Fax: (use number on form) — incomplete forms missing required asterisked items may prevent a fax response and delay or result in denial.

Note

Site-of-Care Selection

Indicate where the medication will be obtained and the intended site of administration. Accredo Specialty Pharmacy is Cigna's nationally preferred specialty pharmacy.

Accredo Specialty Pharmacy (preferred) — ePrescribe, Fax 888.302.1028, Verbal 866.759.1557.
Prescriber's office stock (billing on medical claim)
Retail pharmacy
Home Health / Home Infusion vendor
Specify if patient is a candidate for home infusion and whether physician has an in-office infusion site.

Documentation Required

Required Clinical and Administrative Information

Provide complete clinical and administrative information. All asterisked (*) items on the form must be completed — failure to do so may prevent a fax response and delay or cause denial.

Patient identifiers: patient name, Cigna ID, date of birth, address, phone.
Provider identifiers: physician name, specialty, DEA/NPI/TIN, office contact, phone, fax, office address.
Medication details: selected product (Hycamtin 4mg vial; Topotecan 4mg vial; Topotecan 4mg/4mL solution), ICD-10 code, dose, frequency, duration.
Clinical justification: diagnosis related to use, disease stage, prior therapy, performance status, concurrent agents (names/doses/schedule).
Patient metrics: current height and weight.
Administrative: indicate where medication will be obtained and whether therapy is chronic/long-term.

Denial Risk

Incomplete Form Risk

Incomplete required patient or provider information — including any missing asterisked fields — may prevent processing, delay the review, and could result in denial. Ensure the prescriber signature and attestation are included for final authorization.

Prescriber attestation and signature with date are required.
Missing required fields (patient ID, DOB, NPI/DEA/TIN, medication selection, dosing, diagnosis) increase denial risk.

Where Medication Will Be Obtained / Billing Notes

Billing Rule

Specify where medication will be obtained (Accredo preferred; note billing for office stock)

Indicate on the form where the medication will be obtained and, if applicable, provide facility/dispensing details or home infusion candidacy; Accredo is the preferred specialty pharmacy but providers may select office stock (medical claim billing), retail, or home infusion.

If prescriber’s office stock is selected, note that billing should be on a medical claim form and provide facility name, Tax ID, and address.
If considering home infusion, indicate whether the patient is a candidate and whether the physician has an in‑office infusion site.

Drug Formulation Definitions

Hycamtin / Topotecan (IV) — definition & presentations

FormulationIntravenous topotecan (Hycamtin) — the IV formulation of topotecan supplied for injection.

Presentations listed on formHycamtin 4 mg powder for injection vial; Topotecan 4 mg powder for injection vial; Topotecan 4 mg/4 mL solution for injection vial.

Route of administrationIntravenous (injection) as indicated by vial/powder and solution presentations on the form.

PackagingSingle‑vial presentations: 4 mg powder for injection and 4 mg/4 mL solution for injection as specified.

Clinical Background

Topotecan (Hycamtin) is referenced on the form as the intravenous topoisomerase I inhibitor to be requested by prescribers. The intake collects diagnosis-specific and treatment details to support use in malignancies where topotecan is indicated (for example small cell lung cancer, ovarian and related gynecologic cancers, bone tumors, primary CNS lymphoma and CNS/leptomeningeal disease). Provide the exact product requested, proposed dose, frequency and duration, and supporting clinical information to justify therapy.

Hycamtin 4mg powder for injection vial	medication product listed on form
Topotecan 4mg powder for injection vial	medication product listed on form
Topotecan 4mg/4mL solution for injection vial	medication product listed on form

Item	Detail / Implication
Nationally preferred specialty pharmacy
Accredo Specialty Pharmacy is identified as Cigna's nationally preferred specialty pharmacy (NCPDP 4436920); pharmacy-dispensed orders may be expected to route to Accredo and can be placed via e-prescribe, fax, or verbal order.

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