CurrentCignaPolicy v010124

Vivimusta (bendamustine) prior authorization request form

This document is a Cigna prior authorization form for Vivimusta (bendamustine) used to request coverage/authorization for administration and dispensing; it affects prescribing providers, infusion sites, and specialty pharmacies serving Cigna members.

Policy Summary

PayerCigna

PolicyVivimusta (bendamustine) prior authorization request form

Policy CodePolicy v010124

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including ICD-10, dose, frequency, duration, and required patient and prescriber identifiers to request coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

855-840-1678fax to submit form

800-882-4462urgent phone

Accredopreferred specialty pharmacy

v010124policy id

Coverage Criteria

Policy Summary

PayerCigna

PolicyVivimusta (bendamustine) prior authorization request form

Policy CodePolicy v010124

Change TypeRoutine review — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form including ICD-10, dose, frequency, duration, and required patient and prescriber identifiers to request coverage.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical eligibility and necessity

Coverage considerations based on diagnosis and disease status

Eligible diagnoses: Patient has one of the listed diagnoses: Adult T-cell leukemia/lymphoma (ATLL); Angioimmunoblastic T-cell lymphoma (AITL); Chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL); Hepatosplenic gamma-delta T-cell lymphoma (HSGDTCL); Hodgkin's lymphoma (HL); Multiple myeloma (MM); Peripheral T-cell lymphoma (PTCL); or other specified diagnosis

Form requires selection of diagnosis checkbox and specification where applicable

Disease status for specific indications: When applicable for the selected diagnosis, documentation of disease status is required: relapsed, refractory, or progressive disease as indicated on the form

Form contains diagnosis-specific questions (e.g., HL, ATLL, PTCL, AITL, MM, HSGDTCL) with relapsed/refractory/progressive checkboxes

Indication-specific single‑agent use or prior treatment: For certain diagnoses (e.g., ATLL, HL [palliative], HSGDTCL) indicate if bendamustine will be the only agent used to treat this diagnosis at this time and whether prior treatments were given

Form asks if medication will be the only therapy and whether prior treatment was received for HSGDTCL

Clinical support documentation: Provide disease stage, prior therapy, performance status, and names/doses/schedules of any concurrent agents to support medical necessity

Additional pertinent information section on form

The form does not list any explicit exclusions for Vivimusta (bendamustine). There is no separate exclusions section or checkbox that identifies specific diagnoses, settings, or patient populations that are categorically excluded from coverage on the form.

The form does not state explicit not medically necessary conditions. However, it includes a site-of-care note indicating that, for some Cigna plans, infusion must occur in the least intensive, medically appropriate setting, and asks whether the patient can be redirected to an alternate setting; failure to document suitability or redirection rationale may affect authorization under those plan-specific site-of-care rules.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. The prior authorization form must collect the ICD-10 diagnosis, medication dose, frequency, duration of therapy, and specific administration/dispensing details to support medical necessity.

Medication requested and strength
ICD-10 diagnosis
Dose, frequency, and duration of therapy
Administration/dispensing site and facility details

Denial Risk

Site-of-care requirement

Infusions must occur in the least intensive medically appropriate setting. Per some Cigna plans, failure to document that the infusion will be provided in the least intensive setting may affect coverage.

Least intensive appropriate setting required (e.g., home, physician's office vs hospital outpatient)
If less intensive site is clinically appropriate, document rationale if choosing a higher-intensity setting

Note

Site-of-care redirection assessment

Assess whether the patient is a candidate for redirection to an alternate, less intensive site of care (such as home, physician office, or alternate infusion site). This assessment may require involvement of Specialty Care Options Case Management or a specialty pharmacy to facilitate redirection and care coordination.

Document whether patient is a candidate for redirection and indicate Yes or No on the form
If No, provide medical necessity rationale
If Yes, include plan for coordination with Specialty Care Options Case Manager or specialty pharmacy

Documentation Required

Required documentation

Completed prior authorization form must include required patient and prescriber identifiers, facility/dispensing site information, and supporting clinical documentation. Incomplete forms or missing documentation may delay review or result in denial.

Required patient identifiers: Cigna ID, date of birth, patient name, address, phone
Required prescriber identifiers: Physician name, specialty, DEA/NPI/TIN, office contact, phone, fax
Facility/dispensing site: facility name, tax ID, address (city, state, zip), and state
Clinical documentation: diagnosis, disease stage, prior therapies, performance status, prior response, and concurrent medications (names/doses/schedules)
Attestation and prescriber signature and date

Initial Authorization Requirements

Initial authorization requirements

Information required for initial authorization

Prescriber and patient identifiers: Form must include prescriber name and signature, DEA/NPI/TIN as applicable, patient name, Cigna ID, date of birth, address and contact information (asterisked items)

Form will not return outcome via fax unless asterisked items completed

Medication order details: Document medication requested (Vivimusta 100mg/4mL), ICD-10 diagnosis code, dose, frequency of therapy, and duration of therapy

Medication and dosing fields provided on form

Diagnosis selection and disease status: Select the specific diagnosis from the form and for diagnoses that require it indicate relapsed, refractory, or progressive status (e.g., ATLL, PTCL, AITL, MM, HL, HSGDTCL)

Diagnosis checkboxes and disease‑status questions present on form

Concurrent and prior therapies: Provide prior therapy history and list names, doses, and administration schedules of any agents to be used concurrently

Clinical information section requests prior therapy and concurrent agents

Additional clinical information and attestation: Include disease stage, performance status, and prescriber attestation with signature and date to certify information is accurate

Attestation and signature block present on form

Step	Requirement	Action required prior to authorization
1	Assessment of candidacy for redirection to an alternate, less intensive infusion setting	Document whether patient is candidate for redirection (Yes/No). If No, provide medical necessity rationale on the form; if Yes, note coordination with Specialty Care Options Case Manager

Infusion Location and Site-of-Care Policy

Note

Specify obtaining and administration site (home | office | infusion center | hospital outpatient)

Indicate where the medication will be obtained/infused on the form — options include home, physician's office, infusion center (hospital outpatient), retail or specialty pharmacy — and ensure infusion will occur in the least intensive medically appropriate setting as required by some plans.

Select where medication will be obtained (Accredo Specialty Pharmacy, Hospital Outpatient, Retail, Other, Home Health/Home Infusion, Physician's office stock)
Select where drug will be administered (Patient's Home, Physician's Office, Hospital Outpatient, Other)

Definitions and Key Terms

Vivimusta — definition

TermVivimusta

Generic namebendamustine

Dosage formIntravenous chemotherapeutic agent

Policy identifierv010124

Usage noteForm requests disease‑specific status (relapsed/refractory/progressive) when applicable

Diagnoses listed

Adult T‑cell leukemia/lymphoma (ATLL)Listed on form as an eligible diagnosis

Angioimmunoblastic T‑cell lymphoma (AITL)Listed on form (also shown as immunoblastic lymphadenopathy)

Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL)Listed on form

Hepatosplenic gamma‑delta T‑cell lymphomaListed on form (HSGDTCL / HSCGTCL referenced for prior treatment/refractoriness questions)

Hodgkin's lymphoma (HL)Listed on form (includes palliative use question)

Multiple myeloma (MM)Listed on form (asks if relapsed, progressive, or refractory)

Peripheral T‑cell lymphoma (PTCL)Listed on form

OpenPayer

Vivimusta (bendamustine) prior authorization request form

Coverage Criteria

Drug and Billing Codes

Provider Actions and Authorization Requirements

Initial Authorization Requirements

Step Therapy / Site-of-Care Assessment

Infusion Location and Site-of-Care Policy

Definitions and Key Terms

Background