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Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- IVIG (Intravenous Immune Globulin)-

Notice: Failure to complete this form in its entirety may result in delayed

processing or an adverse determination for insufficient information.

PROVIDER INFORMATION

PATIENT INFORMATION

* Provider Name:

**Due to privacy regulations we will not be able to respond via

fax with the outcome of our review unless all asterisked (*)

Specialty:

* DEA or TIN:

items on this form are completed**

Office Contact Person:

* Patient Name:

Office Phone:

* CIGNA ID:

Office Fax:

* Date Of Birth:

* Is your fax machine kept in a secure location?

Yes

* Patient Street Address:

* May we fax our response to your office?

Yes

Office Street Address:

City

State

Zip

City

State

Zip

Patient Phone:

Medication requested:

Gamimune N

Carimune

Baygam

Gammar

Carimune NF

Flebogamma

Polygam S/D

Panglobulin NF

Iveegam EN

Gammagard S/D

Venoglobulin-S

Other (Please specify):

Gammagard Liquid Immune Globulin, Gamma

Dose requested:	Dose (mg/kg):	JCode:	CPT Code:
Frequency of administration:	Duration of therapy:		Patient’s current weight:

Where will this medication be obtained?

CIGNA Tel-Drug (CIGNA's nationally preferred specialty pharmacy)

Prescriber’s office stock (billing on a medical claim form) Home Health / Home Infusion vendor (name):

Retail pharmacy Other (please specify):

Address:TIN#:

Please specify the following:

Has this patient been treated with IVIG in the past? Yes No

If Yes, please complete reauthorization criteria in addition to the diagnosis specific criteria on this form.

1. Primary Immunodeficiency

Congenital / X-linked agammaglobulinemia-(XLA) Bruton’s Disease

Autosomal recessive agammaglobinulinemia – (ARA)

Autosomal recessive hyper-IgM syndrome (HIM)

Congenital Hypogammaglobulinemia

ICF Syndrome

Common variable immunodeficiency (CVID)

Selective IgA Deficiency

Selective IgG subclass deficiencies (IGGSD)

Intravenous Immune Globulin for CIGNA Healthcare Individuals – Page 1 of 5

Specific Antibody Deficiency (SAD)

Transient hypogammaglobulinemia of infancy

Hypogammaglobulinemia, unspecified

Severe combined immunodeficiency disorder (SCID)

Wiskott Aldrich syndrome (WAS)

Ataxia-telangiectasia (A-T) including (NBS)

DiGeorge syndrome (DGS)

Hyper-IgM syndrome

X-linked lymphoproliferative syndrome

(WHIM) warts, hypogammaglobulinemia, immunodeficiency, and myelokathexis

Defects of NF-κB regulation Defects of Toll-like receptor signaling

Other (please specify):

Pre Treatment Immunoglobulin levels copies of lab reports required, including: Total immunoglobulin levels:

Ig G subclasses (if applicable):

B cells (if applicable):

Genetic testing confirming the diagnosis (if applicable):

Vaccine response results

copies of lab reports required, including

pre & post vaccination responses for pneumococcal, diphtheria, tetanus vaccines

Details of recurrent infections

copies of clinical records required that address the following: Sites of infections:

When did the infections start?

How many episodes per year?

How many courses of antibiotics per year?

List of the names of antibiotics and durations:

Are underlying conditions such as asthma, allergic rhinitis under control? Yes No

Supporting diagnostic imaging or lab results of recurrent infections where applicable:

For reauthorization requests

copies of clinical records required, including: Trough Ig G levels:

Response to IVIG:

2.Secondary Immunodeficiency

High-risk, preterm, low-birth-weight neonates

Multiple Myeloma

copies of clinical records and lab reports required: Has the disease been stable for 3 months? Yes No Pre treatment Ig G level:

Number of recurrent sino pulmonary infections per year:

CLL

copies of clinical records and lab reports required: Pre treatment Ig G level:

Number of recurrent sino pulmonary infections per year:

Intravenous Immune Globulin for CIGNA Healthcare Individuals – Page 2 of 5

Allogeneic hematopoietic stem cell transplant (HSCT) copies of clinical records and lab reports required: Date of transplant:

Pre treatment Ig G levels:

Number of recurrent sino pulmonary infections per year:

Allosensitized solid organ transplants

Bone marrow transplantation

Date of transplant:

HIV

CD 4 counts:

Current antiretroviral medications:

	3. Hematology

Acute Idiopathic Thrombocytopenic Purpura (ITP)
Is there active bleeding? Yes	No
What is the platelet count?	Date:
Are there any major surgical procedures planned? Yes		No	Date:

Chronic Idiopathic Thrombocytopenic Purpura (ITP)
copies of clinical records and lab reports required:
What is the duration of ITP?
Are there any other concurrent illness/disease explaining thrombocytopenia?		Yes	No
Was there prior treatment with a reasonable course of corticosteroids or splenectomy?			Yes
If Yes, please specify which drugs were tried and the treatment dates:
What is the platelet count?	Date:

HIV-associated Thrombocytopenia
copies of clinical records and lab reports required
Is there active bleeding?	Yes		No
What is the current platelet count?					Date:
Are there any major surgical procedure planned?					Yes	No		Date:

Fetal Alloimmune Thrombocytopenia (FAIT)
Is there a documentation of maternal antibodies to paternal platelet antigen? Yes									No
Are there any previous pregnancies complicated by FAIT?						Yes		No
Fetal platelet counts if available:

Idiopathic Thrombocytopenic Purpura (ITP) in pregnancy
Is there a history of previously delivered infant(s) with autoimmune thrombocytopenia? Yes										No
What is the current platelet count?
LMP:
Is there any bleeding?	Yes	No
Is the thrombocytopenia refractory to steroids?					Yes	No
Is there a history of splenectomy?			Yes	No

Post-transfusion purpura
Post-transfusion purpura

Neonatal isoimmune hemolytic disease
Is IVIG given in conjunction with phototherapy?					Yes	No

Warm type autoimmune hemolytic anemia
Is there a predominance of Ig G (warm) antibodies? Yes							No
Is there a failure, contraindication, or intolerance to available alternative therapies?									Yes	No
If Yes, please mark all that apply:
azathioprine				cyclophosphamide				cyclosporine
prednisone				plasmapheresis				splenectomy		other (please specify):

Intravenous Immune Globulin for CIGNA Healthcare Individuals – Page 3 of 5

Anemia related to chronic parvovirus B19 infection
What is the hemoglobin?
Is there evidence of viremia? Yes		No

Evan’s syndrome
Is there a failure, contraindication, or intolerance to available alternative therapies? Yes					No
If Yes, please mark all that apply:
azathioprine	cyclophosphamide		cyclosporine	prednisone

4. Neurology

Neuropathies:

Acute inflammatory demyelinating polyneuropathy (AIDP) Chronic inflammatory demyelinating polyneuropathy (CIDP)

Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) (Lewis Sumner Syndrome) Multifocal Motor Neuropathy (MMN)

Copies of clinical records and lab reports required that includes the following:

Comprehensive H&P including duration of symptoms and detailed neurological examination

Copy of NCV/EMG reports

CSF results including CSF protein, cell count and VDRL

Other pertinent tests if applicable, e.g., antibody testing, IPEP, imaging studies

For reauthorization requests:

Please provide updated progress notes that includes the following information

Symptoms and objective exam findings such as strength measurement, sensory testing and reflexes and level of function

Titration efforts since last renewal

Updated test results (e.g., if NCV/EMG has been repeated)

Myasthenia gravis
copies of clinical records and lab reports required:
Is a thymectomy planned or has the individual undergone thymectomy? Yes		No
If Yes, on what date?
Is the individual initiating immunosuppressive treatment? Yes	No
If Yes, which therapy?

If the request is for the treatment of acute crisis, please provide clinical documentation of physical findings indicative of acute crisis.

Relapsing-Remitting Multiple Sclerosis

copies of clinical records and lab / Xray reports required supporting diagnosis and failure of standard therapy: Is there any failure, contraindication, or intolerance to standard conventional therapies (e.g. interferon beta, glatiramer)?

Yes	No
If so, which therapies?

Guillain-Barré syndrome (GBS)
What was the date of the initial onset of symptoms?
Is the individual currently on plasmapheresis? Yes		No

Lambert-Eaton myasthenic syndrome (LEMS)

Is there any failure, contraindication, or intolerance to other symptomatic therapies (e.g., acetylcholinesterase inhibitors

such as mestinon and immunosuppressants such as prednisone, azathioprine)? Yes	No

If so, which therapies?

Stiff Person Syndrome (Moersch-Woltmann Syndrome)

Prior failure, contraindication, or intolerance to available standard medical therapy (please mark all that apply):

diazepam	baclofen	phenytoin
clonidine	tizanidine	Other (please specify):

Intravenous Immune Globulin for CIGNA Healthcare Individuals – Page 4 of 5

azathioprine cyclophosphamide other treatment? (please specify):

5. Rheumatologic Disorders

Dermatomyositis or Polymyositis

copies of clinical records and lab reports required Please provide biopsy results;

Does the individual have any failure of standard medical therapy (at least a 4 month trial of corticosteroids and/or

immunosuppressants)? Yes

Is there any profound, rapidly progressive and/or potentially life threatening muscular weakness (refractory or intolerant

to previous therapy)? Yes

Please provide serum creatine kinase (CK) levels

Please provide any muscle strength scales

Kawasaki disease

What was the date of the onset of symptoms? Will IVIG be used in conjunction with aspirin?

Yes

6. Infectious Disease

Staphylococcal or streptococcal toxic shock syndrome

Is the infection refractory to treatment?	Yes	No
If Yes, what therapies have been tried?
Is an undrainable focus present? Yes	No

Is persistent oliguria with pulmonary edema present? Yes

HIV-positive children and adolescents

Has the individual been exposed to measles or live in a high-prevalence measles area? Will IVIG be used to prevent bacterial infections? Yes No

Yes

Hepatitis A

Is intramuscular gamma globulin contraindicated? Yes No If Yes, what is the contraindication?

Tetanus / Varicella

Is Tetanus or Varicella Immune Globulin available? Yes No

7. Dermatology

Pemphigus

Pemphigoid

Epidermolysis Bullosa Acquisita

Is there a failure, contraindication, or intolerance to available alternative therapies? If Yes, please mark all that apply:

corticosteroids CellCept

Yes

Does the individual have rapidly progressive disease in which a clinical response can not be affected quickly enough using conventional agents? Yes No

CIGNA HealthCare’s coverage position on this and other medications may be viewed online at:

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions

Please fax completed form to (800)390-9745. Due to the clinical information required, requests for IVIG cannot be accepted via phone.

Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent, it is important that you call Pharmacy Services to have the request expedited. View our formulary on line at http://www.cigna.com.

“CIGNA Pharmacy Management” or “CIGNA HealthCare” refer to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.

V 041510

Intravenous Immune Globulin for CIGNA Healthcare Individuals – Page 5 of 5

Question	Answer
Form Name	Cigna Ivig Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	cigna retro authorization form, cigna medicare part b prior authorization, cigna healthcare prior ivig form, cigna ivig form

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