Cigna: Briumvi Payer Policy

Created by C. Denise Burrell, Modified on Fri, 24 Jan at 6:46 PM by C. Denise Burrell

Cigna: Briumvi Payer Policy (Beta Access)

HCPCS Code(s):	J2329
Precertification Required?	✅ Yes (Click Here for Full Policy)
Step Therapy Required?	Not Specified (Click Here for Full Policy)
Provider Fax Form:	Briumvi Fax Form(✅ Available in SamaCare)
FDA Approved Indications:	Relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults
Recommended Dosage:	Not Specified

Documentation is required where noted in the criteria. Documentation may include, but not limited to, chart notes, laboratory tests, claims records, and/or other information.

Conditions Not Covered

Any other use is considered experimental, investigational, or unproven, including the following (this list may not be all-inclusive; criteria will be updated as new published data are available):

1. Concurrent Use with Other Disease-Modifying Agents Used for Multiple Sclerosis.

These agents are not indicated for use in combination (See Appendix for examples). Additional data are required to determine if the use of disease-modifying multiple sclerosis agents in combination is safe and provides added efficacy.

Initial Approval

The patient meets all the following (i, ii, and iii):

Patient is ≥ 18 years of age;
- AND
Documentation the patient has a relapsing form of multiple sclerosis;
- AND
Note: Examples of relapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease. iii. Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Continutaion Criteria

The patient meets all of the following (i, iii, iii, and iv):

Note: A patient who has received < 1 year of therapy or who is restarting therapy with Briumvi should be considered under criterion 1A (Multiple Sclerosis [Relapsing Forms], Initial Therapy).

Patient is ≥ 18 years of age;
- AND
Documentation the patient has a relapsing form of multiple sclerosis; AND
- Note: Examples of relapsing forms of multiple sclerosis include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease.
Patient meets one of the following [(1) or (2)]:
- Patient experienced a beneficial clinical response when assessed by at least one objective measure; OR
- Note: Examples include stabilization or reduced worsening in disease activity as evaluated by magnetic resonance imaging (MRI) [absence or a decrease in gadolinium enhancing lesions, decrease in the number of new or enlarging T2 lesions]; stabilization or reduced worsening on the Expanded Disability Status Scale (EDSS) score; achievement in criteria for No Evidence of Disease Activity-3 (NEDA3) or NEDA-4; improvement on the fatigue symptom and impact questionnairerelapsing multiple sclerosis (FSIQ-RMS) scale; reduction or absence of relapses; improvement or maintenance on the six-minute walk test or 12-Item Multiple Sclerosis Walking Scale; improvement on the Multiple Sclerosis Functional Composite (MSFC) score; and/or attenuation of brain volume loss.
- Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling sensation; AND
- Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

When coverage is available and medically necessary, the dosage, frequency, duration of therapy, and site of care should be reasonable, clinically appropriate, and supported by evidence-based literature and adjusted based upon severity, alternative available treatments, and previous response to therapy.

Sources: https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0545_coveragepositioncriteria_ublituximab.pdf

⚠️ Disclaimer: This article is a policy summary and does not guarantee coverage or approval.

Policies may vary based on plan, payer-specific rules, state or regional requirements, benefit structure, formulary placement, and patient-specific considerations like diagnosis or clinical history. Always review the full policy and confirm details directly with the payer to ensure compliance.

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