CurrentCignaPolicy N/A

Tymlos Prior Authorization Form

This document is a Cigna prior authorization request form to be completed by prescribers seeking coverage for Tymlos (abaloparatide) including patient, clinical, and dispensing information to support a coverage decision.

Policy Summary

PayerCigna

PolicyTymlos Prior Authorization Form

Policy CodePolicy N/A

Change TypeAdministrative prior authorization form

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; include all asterisked fields, clinical checklist, attestation and prescriber signature to support review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted on this form.

1Form version identifier

5 business daysStandard response time

Policy summary

This is a Cigna prior authorization request form for Tymlos (abaloparatide). The form collects patient, clinical, and dispensing information including medication requested (Tymlos 80 mcg/dose prefilled pen), dose/frequency/duration, indication, fracture/T-score/FRAX details, prior therapy and attestation with prescriber signature to determine coverage. The document identifies Cigna's nationally preferred specialty pharmacy as Accredo and provides submission routes including fax and online (CoverMyMeds or SureScripts). Status: CURRENT; standard response time: 5 business days.

What prescribers must do

Prior Authorization

Complete and fax prior authorization form

Fax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts. Include all asterisked fields, the clinical checklist, the required attestation, and the prescriber signature to support review.

Prior Authorization

Urgent requests

For urgent requests the prescriber must call (800) 882-4462 to attest that the standard review time may seriously jeopardize the patient’s life, health, or ability to regain maximum function. The standard response time for prescription drug coverage requests is 5 business days.

Documentation Required

Clinical documentation to support coverage

Provide clinical documentation including T-score, history of fragility fractures, FRAX 10-year probabilities if applicable, prior therapy history (including agents, doses, schedules), and planned dispensing source. Note the plan or its designees may perform routine audits and request medical records to verify the information provided.

Billing Rule

Specify dispensing source

Indicate where the medication will be obtained (options include Accredo Specialty Pharmacy, prescriber’s office stock billed on a medical claim, retail pharmacy, home health/home infusion vendor, or other). If dispensed by a facility or doctor, include facility name, address, state, and Tax ID.

Accredo Specialty Pharmacy
Prescriber office stock (medical claim)
Retail pharmacy
Home Health / Home Infusion vendor
Other (specify)

Definitions & logistics

Cigna's nationally preferred specialty pharmacy is Accredo; the form notes Accredo ordering options (E-prescribe, Fax 888.302.1028, Verbal 866.759.1557) and lists where the medication will be obtained including Accredo, prescriber's office stock, retail pharmacy, home health/home infusion, or other. Submission routes for the prior authorization form include faxing the completed form to (855) 840-1678 and submitting online via CoverMyMeds or SureScripts. The form requests clinical and administrative details (clinical checklist items, T-score/FRAX/fracture history, prior therapy, facility/tax ID if applicable, attestation and prescriber signature) to support the coverage review.

Definitions and thresholds

Accredo (term)Cigna's nationally preferred specialty pharmacy (contact/fax/verbal ordering details provided).

T-score threshold≤ -2.5 (qualifies for one pathway)

FRAX 10-year major osteoporotic fracture probability≥ 20% (required if T-score between -1.0 and -2.5)

FRAX 10-year hip fracture probability≥ 3% (required if T-score between -1.0 and -2.5)