CurrentCignaPolicy N/A

Tezspire

Cigna prior-authorization / specialty pharmacy request form to obtain coverage/approval and order Tezspire (tezepelumab) across listed indications (asthma, CRSwNP, atopic dermatitis, COPD, chronic spontaneous urticaria, other). The form collects patient, prescriber, clinical criteria, site-of-care, dispensing source, and administration details to support medical-claim or pharmacy benefit processing and utilization management.

Policy Summary

PayerCigna

PolicyTezspire

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts, including all required asterisked fields to receive a faxed response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes.

5Primary Indications listed on form

6Required clinical test/therapy thresholds captured

Policy overview & scope

Cigna prior-authorization / specialty pharmacy request form to obtain coverage/approval and order Tezspire (tezepelumab) across listed indications: Asthma, Atopic Dermatitis, COPD, Chronic Rhinosinusitis with Nasal polyps (CRSwNP), Chronic Spontaneous Urticaria, and other/unspecified diagnoses. The form captures patient identifiers and contact details, prescriber information (specialty, DEA/NPI/TIN, office contact), medication requested (Tezspire 210 mg/1.91 mL syringe or other), ICD-10 diagnosis, dose/quantity/frequency/duration, and urgency of the request.

The form is designed to collect indication-specific clinical criteria and documentation to support coverage determination and dispensing, including: prior controller therapy and duration (for asthma: ≥ 3 consecutive months of an inhaled corticosteroid plus at least one additional controller or use of a combination inhaler), exacerbation history and objective lung-function or challenge testing (FEV1 < 80% predicted; or bronchodilator/visit/baseline response of >12% AND >200 mL; or positive exercise/bronchial challenge), and for CRSwNP: evidence by exam/endoscopy/CT, duration ≥ 6 months, ≥2 symptoms for ≥ 8 weeks, prior intranasal corticosteroid for ≥ 4 weeks, and prior systemic corticosteroid course defined as ≥ 3 consecutive days within the previous year (or contraindication or prior surgery).

The form captures site-of-obtainment and administration options to support benefit routing and billing: Accredo Specialty Pharmacy (preferred), hospital outpatient, retail, home health/home infusion, physician office stock (billing on medical claim), and administration site (patient home, physician office, hospital outpatient, other). It also records facility/dispensing tax ID when applicable and asks whether the drug will be obtained from Accredo.

For patients currently receiving Tezspire the form requests continuation-assessment information including whether the patient has received at least 6 months of therapy, whether they will continue concomitant inhaled or intranasal corticosteroid therapy (required), and whether the prescriber documents clinical response (examples provided: reduced exacerbations, improved lung function, reduced polyp size, improved symptoms, decreased steroid requirement).

Submission instructions and administrative details: fax completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts; urgent requests should also be called to (800) 882-4462. The form notes that all asterisked fields must be completed to receive a faxed response and requires prescriber attestation, signature, and date; the Health Plan may audit and request medical records to verify information.

Policy metadata & thresholds

PayerCigna

Policy titleTezspire (tezepelumab) prior authorization / specialty pharmacy ordering form

Policy number

StatusCURRENT

Primary indications (count)5 (Asthma; Atopic Dermatitis; COPD; Chronic Rhinosinusitis with Nasal polyps; Chronic Spontaneous Urticaria)

Thresholds summaryFEV1 <80% predicted; bronchodilator response >12% AND >200 mL in FEV1 (including between visits or from baseline after ≥4 weeks); ≥3 consecutive months inhaled corticosteroid + additional controller; ≥4 weeks intranasal corticosteroid for CRSwNP; prior systemic corticosteroid course ≥3 consecutive days within previous year; minimum Tezspire trial for continuation assessment ≥6 months

Coverage criteria — initiation and continuation by indication

General submission and indication selection

Form collects required data elements and indication-specific clinical criteria for prior authorization

Required submission fields

Patient identifying information: Completed patient identifying information required for review
Prescriber details: Prescriber specialty, DEA/NPI/TIN, contact details provided
Medication requested specified (Tezspire 210 mg syringe or other)
Indication selection: Indication selected from provided list (Asthma; Atopic Dermatitis; COPD; Chronic Rhinosinusitis with Nasal polyps; Chronic Spontaneous Urticaria; Other)
Site of obtainment and administration selected (Accredo Specialty Pharmacy, hospital outpatient, retail, home health/home infusion, physician office stock, etc.)

Submission, documentation & billing actions

Prior Authorization

Submit completed prior-authorization form

Fax the completed prior-authorization form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. All asterisked (*) fields on the form must be completed in order to receive a faxed response.

Prior Authorization

Urgent request procedure

For urgent requests, call (800) 882-4462 to expedite review in addition to fax submission of the completed form.

Documentation Required

Provide clinical evidence for indication-specific criteria

Provide clinical documentation to support the indication-specific criteria, including prior controller therapy duration, exacerbation history, objective lung-function testing results, prior systemic corticosteroid courses, prior surgeries, and evidence of prescriber specialty or consultation.

Duration of prior controller therapy (e.g., ≥3 consecutive months of inhaled corticosteroid plus at least one additional controller)
Asthma exacerbation history (eg, ≥2 courses of systemic corticosteroids in prior year, or hospitalization/ED/urgent care visit)
Objective lung-function testing: FEV1 percent predicted, bronchodilator response (>12% and >200 mL), challenge or exercise test results
Prior systemic corticosteroid courses (e.g., ≥3 consecutive days within previous year) and details
Prior sinus/nasal polyp surgery when applicable
Prescriber specialty or documentation of consultation (allergist, immunologist, pulmonologist, or ENT as applicable)

Billing Rule

Specify site of product obtainment and administration

Indicate where the drug will be obtained and where it will be administered. Options include Accredo Specialty Pharmacy (Cigna’s preferred specialty pharmacy), hospital outpatient, retail pharmacy, home health/home infusion vendor, or physician office stock. If physician office stock is used, billing should be submitted on a medical claim form. Accredo ordering options (e-prescribe, fax, verbal) are provided on the form.

Accredo Specialty Pharmacy (preferred specialty pharmacy) — orders via e-prescribe, fax, or verbal
Hospital outpatient
Retail pharmacy
Home health / home infusion vendor
Physician's office stock — bill on a medical claim form

Documentation Required

Attestation and prescriber signature required

The prescriber must attest that the information provided is true and accurate and must sign and date the form. The Health Plan may perform audits and request medical records to verify the information reported.

Policy Summary

PayerCigna

PolicyTezspire

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online via covermymeds.com or SureScripts, including all required asterisked fields to receive a faxed response.

SourceLink

On This Page

OpenPayer

Tezspire

Policy overview & scope

Coverage criteria — initiation and continuation by indication

Code lists requested on form

Submission, documentation & billing actions

Key definitions

Document changes & history