ZYNTEGLO (betibeglogene autotemcel) PRIOR AUTHORIZATION FORM
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This document is a prior authorization form and instructions for requesting coverage of Zynteglo for Geisinger Health Plan beneficiaries; it affects prescribers, billing providers, and plan beneficiaries seeking authorization for Zynteglo.
No material clinical or coverage changes in this revision.
Authorization Criteria for Zynteglo
Authorization criteria
Covered when ALL of the following are met:
ALL of the following
- Prescriber confirms beneficiary has NOT received prior gene therapy.
Form includes checkbox to confirm beneficiary has NOT received prior gene therapy; submit supporting documentation (e.g., chart/clinic notes).
- Prescriber confirms beneficiary has NOT received a prior allogeneic hematopoietic stem cell transplant (HSCT).
Form includes checkbox to confirm no prior allogeneic HSCT; submit supporting documentation.
- Genetic testing confirming the diagnosis of β‑thalassemia is provided.
Form includes checkbox for genetic testing; submit the genetic test results.
- Transfusion burden meets threshold: history of at least 100 mL/kg/year OR at least 8 packed red blood cell transfusion episodes per year, documented over the prior 2 years.
Must submit transfusion history documentation (e.g., transfusion records, clinic notes).
- Diagnosis code (DX code) provided on the form.
DX code is required on the form; include supporting diagnostic documentation and test results.
- Prescriber completes beneficiary and prescriber information, signs and dates the form, and submits the completed form with required clinical documentation.
Submission options: PromptPA portal (https://ghp.promptpa.com) or fax to Geisinger Health Plan at 570-271-5610.
Diagnosis and Related Coding
| Diagnosis code (DX code) required on form; no specific ICD-10 code listed on form. |
Submission Instructions and Required Attestations
Submit completed prior authorization form with required clinical documentation
Submit the completed prior authorization form along with required clinical documentation (recent chart/clinic notes, diagnostic evaluations, test results). Submission options: use the PromptPA portal (https://ghp.promptpa.com) or fax the completed form and supporting records to Geisinger Health Plan at 570-271-5610.
- Include recent chart/clinic notes, diagnostic evaluations, and relevant test results.
- Submit via PromptPA: https://ghp.promptpa.com or fax to 570-271-5610.
Prescriber attestation and required documentation (genetic testing, transplant/gene therapy status, transfusion history)
The prescriber must complete beneficiary and prescriber information on the form, attest that the beneficiary has not received prior gene therapy or a prior allogeneic hematopoietic stem cell transplant, confirm genetic testing that diagnoses β‑thalassemia, provide transfusion history, and sign and date the form.
- Complete beneficiary and prescriber identifying information (name, ID, DOB, prescriber NPI, contact details).
- Attest that the beneficiary has NOT received prior gene therapy and has NOT received a prior allogeneic hematopoietic stem cell transplant.
- Provide genetic testing confirming diagnosis of β‑thalassemia and documentation of transfusion history (≥100 mL/kg/year or ≥8 transfusion episodes/year over the prior 2 years).
- Sign and date the form.
Drug and Term Definitions
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