CurrentCignaPolicy N/A

Flolan_Veletri_Prior_Authorization_Form

A Cigna prior authorization form to collect patient, prescriber, and clinical information to support coverage decisions for epoprostenol (Flolan, Veletri) for pulmonary hypertension and related diagnoses. The form documents indication, prior therapies, diagnostic confirmation (right heart catheterization), prescriber specialty, and logistics for drug sourcing and administration.

Policy Summary

PayerCigna

PolicyFlolan_Veletri_Prior_Authorization_Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider must complete all asterisked items and attach required documentation (right heart catheterization reports, chart notes) when indicated; incomplete forms may result in inability to respond by fax or denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Primary Indications Listed

1Preferred Specialty Pharmacy

1Standard response time (business days)

Coverage Summary

This is a Cigna prior authorization form to collect patient, prescriber, and clinical information to support coverage decisions for epoprostenol (Flolan, Veletri) for pulmonary hypertension and related diagnoses (PAH WHO Group 1, CTEPH, COPD/other indications). Coverage stance: covered_with_criteria. Required documentation includes confirmation of diagnosis by right heart catheterization for PAH where indicated and involvement of a cardiologist or pulmonologist; the form also requires medication, dosing, administration details, and sourcing information.

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Medical Necessity / Clinical Criteria

General Prior Authorization Information / Required Documentation

Covered when ALL of the following administrative items are provided:

ALL of the following

Patient identifying information: Completed patient identifying information: Physician Name, Specialty, DEA/NPI/TIN, Office Contact Person, Patient Name, Cigna ID, Date of Birth, Patient Street Address, Patient Phone, Office Phone, Office Fax, Office Street Address, City/State/Zip
Asterisked items must be completed to receive faxed response per form.
Medication requested specified (epoprostenol / Flolan / Veletri / other)
Diagnosis code: ICD-10 diagnosis code provided
Dosing and billing: Dose, quantity, frequency of administration, duration of therapy, and J-code (if injectable) provided
Source of medication indicated (Accredo specialty pharmacy, prescriber's office stock, retail pharmacy, home health/home infusion vendor, or other)
Accredo is Cigna's nationally preferred specialty pharmacy.
Facility/dispensing info: Facility/dispensing provider information if injectable (Facility Name, State, Tax ID#)
Attestation and prescriber signature and date
Form requires prescriber attestation and signature.

Clinical Criteria for Pulmonary Arterial Hypertension (PAH) - WHO Group 1

Coverage for PAH Group 1 epoprostenol use is considered when ALL applicable clinical criteria are met:

ALL of the following

Group 1 PAH confirmation and prescriber: Does the patient have WHO Group 1 PAH?; Is the medication being prescribed by, or in consultation with, a cardiologist or a pulmonologist?
Yes/No must be indicated; prescriber specialty required.
Right heart catheterization documentation
- If currently receiving epoprostenol: If currently receiving: Has the patient had a right heart catheterization?; If currently receiving: Did the results of the right heart catheterization confirm diagnosis of WHO Group 1 PAH?
  Yes/No must be indicated.
- If not currently receiving epoprostenol:

Criteria for Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

Coverage for CTEPH when ALL applicable criteria are met:

ALL of the following

Indication is CTEPH: Is the indication CTEPH?
Yes/No must be indicated.
Prescriber specialty requirement: Is the medication being prescribed by, or in consultation with, a cardiologist or a pulmonologist?
Yes required.

Other Indications / COPD use

Other diagnoses must be specified and supported by clinical information:

ALL of the following

COPD without PAH: If diagnosis is COPD in a patient without PAH Group 1, indicate and provide supporting clinical rationale
Provide supporting clinical rationale.
Other indications: For other indications, provide diagnosis and supporting clinical information

Provider Actions & Prior Authorization Requirements

Prior Authorization

Submit completed prior authorization form

Provider must complete all asterisked items on the prior authorization form and attach required documentation when indicated; incomplete forms may result in inability to respond by fax or denial.

Right heart catheterization reports
Chart notes

Documentation Required

Right heart catheterization documentation required

For patients not currently receiving epoprostenol, documentation confirming a prior right heart catheterization and the results must be attached or the request could be denied. Acceptable documentation includes chart notes and catheterization laboratory reports; previously provided right heart catheterization documentation submitted for prior authorization of another PAH medication is considered to meet this requirement.

Prior documentation provided for another PAH medication may satisfy this requirement

Prior Authorization

Specialty pharmacy preference

Medication orders can be placed with Accredo, Cigna's nationally preferred specialty pharmacy, and the source of the medication must be indicated on the form.

Accredo is Cigna's nationally preferred specialty pharmacy; indicate source of medication on the form

Documentation Required

Prescriber specialty requirement

The prescribing physician should be a cardiologist or a pulmonologist, or documentation of consultation with one should be provided for PAH and CTEPH indications.

Prescriber should be a cardiologist or pulmonologist or document consultation

Denial Risk

Risk of denial for missing documentation

Requests that lack required diagnostic documentation or have incomplete responses may be denied. Medical documentation specific to the right heart catheterization must be attached when indicated; missing or incomplete documentation may lead to denial.

Missing right heart catheterization reports
Missing catheterization laboratory reports
Absent chart notes supporting catheterization results
Incomplete asterisked items on the form

Background

This form is intended to collect the administrative and clinical information needed to support prior authorization review for epoprostenol products (Flolan, Veletri) for PAH (WHO Group 1), CTEPH, COPD/non-PAH uses, and other indications. It documents patient and prescriber identifiers, the requested medication and dosing (including J-code if injectable), indication, prior therapies, and logistics for drug sourcing and administration. For PAH, the form emphasizes the need to document right heart catheterization results (chart notes or cath lab reports attached) to confirm WHO Group 1 PAH and requires that the medication be prescribed by or in consultation with a cardiologist or pulmonologist.

Definitions

WHO Group 1 PAHPulmonary arterial hypertension as classified by World Health Organization Group 1.

Idiopathic PAH vasoreactivity pathway

Idiopathic PAH initial: Does the patient have idiopathic PAH?
Yes/No must be indicated.
CCB trial or contraindication: If idiopathic PAH: Has the patient tried one calcium channel blocker (CCB) therapy (e.g., amlodipine, nifedipine ER)?; If CCB not tried: Is the patient unable to take CCB therapy? (reasons may include right heart failure or decreased cardiac output)
Yes/No must be indicated.
Vasodilator testing: If CCB not tried and unable: Did the patient have vasodilator testing?; If unable to undergo vasodilator testing according to prescriber: Has the patient had an acute response to vasodilator testing during right heart catheterization (example response defined as decrease in mPAP >=10 mm Hg to absolute mPAP <40 mm Hg without decrease in cardiac output)?
Yes/No must be indicated; example acute response criteria provided.

OpenPayer

Flolan_Veletri_Prior_Authorization_Form

Coverage Summary

Medical Necessity / Clinical Criteria

Provider Actions & Prior Authorization Requirements

Coding

Background