prior_authorization_request_form_tyenne
This document is a Cigna prior authorization request form for Tyenne (tocilizumab) intravenous vials, to be completed by prescribers requesting coverage/authorization across multiple indicated diagnoses and care settings. It collects patient, prescriber, clinical, prior-therapy, administration site, and pharmacy sourcing information required for review.
No material clinical/coverage changes in this prior authorization form.
Tyenne (tocilizumab) prior authorization request form — summary
This is a Cigna prior authorization request form for Tyenne (tocilizumab) intravenous vials, to be completed by prescribers requesting medical coverage/authorization across multiple rheumatologic and inflammatory diagnoses and care settings. The form requires completion of patient and prescriber identification and contact fields (asterisked items are required for privacy-regulated responses), selection of the specific Tyenne vial presentation requested (80 MG/4 ML, 200 MG/10 ML, or 400 MG/20 ML), the indication/diagnosis, whether this is a new start or continuation, and documentation of clinical status. It collects prior therapy details (drug name, strength, dates, duration, results, intolerances/contraindications), specialist involvement or attestations (for example, rheumatologist, oncologist, or disease-specific specialist), intended administration site (home, physician office, hospital outpatient, other), and where the medication will be obtained (including Accredo specialty pharmacy, hospital outpatient, retail, home health/home infusion, physician office stock, or other) to inform coverage and site-of-care decisions.