CurrentCignaPolicy N/A

prior_authorization_form_for_durysta

Prior authorization form to request coverage/approval for Durysta 10 mcg ophthalmic implant, capture patient, prescriber, clinical information, prior therapy trials, site of administration, and dispensing source selection. It governs submission details (fax/phone), urgency designation, and documentation required for review.

Policy Summary

PayerCigna

Policyprior_authorization_form_for_durysta

Policy CodePolicy N/A

Change TypeAdministrative form (no material change)

Effective Date

Next Review Date

Key ActionProviders must document trials of at least two ophthalmic prostaglandins OR two alternatives from different pharmacologic classes including drug name, strength, dates, duration, and outcomes or intolerances.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes; form captures required clinical and administrative information for prior authorization of Durysta.

1Form pages (single prior authorization form)

Durysta 10 mcgMedication requested

Policy overview

Prior authorization form to request coverage/approval for Durysta 10 mcg ophthalmic implant. Captures patient and prescriber identifiers, diagnosis and clinical information, intent for ophthalmologist administration, documentation of prior therapies and outcomes, specification of eye(s) and re-treatment status, facility/doctor dispensing and administering details, medication obtainment source, and prescriber attestation/signature. Submission options include fax and online, with an option to mark the request as Urgent and an expedited phone number to call.

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Form submission and clinical information requirements

Requests should include ALL of the following information to support authorization:

Patient identifiers: Patient name, Cigna ID, date of birth, patient street address, patient phone
Prescriber identifiers: Physician name, specialty, DEA, NPI or TIN, office contact person, office phone, office fax, office street address
Medication requested: Durysta 10 mcg implant
Diagnosis selection: open-angle glaucoma OR ocular hypertension OR other (specify)
Ophthalmologist administration attestation: Indicate whether medication will be administered by/under supervision of an ophthalmologist
Yes/No checkbox required
Trials of ophthalmic prostaglandins: Document trials of covered alternatives (ophthalmic prostaglandins) including drug name, strength, dates taken, duration, documented results, intolerances/adverse reactions
Form lists example prostaglandins and other ophthalmic products
Trials of other ophthalmic classes: Document trials of other ophthalmic classes (e.g., beta-blockers, alpha-agonists, carbonic anhydrase inhibitors, rho kinase inhibitor) including drug name, strength, dates taken, duration, documented results, intolerances/adverse reactions
Outcomes for covered alternatives: Indicate which of the following is true regarding covered alternatives: tried 2 alternatives but ineffective; tried 2 alternatives but discontinued due to adverse events; or other (specify)
Eye(s) to be treated: Specify eye(s) to be treated: right, left, or both
Re-treatment indication: Indicate if this is re-treatment in same eye(s): Yes/No
Concurrent iDose TR use: Indicate if patient will also be using iDose TR in same eye(s): Yes/No; if yes provide rationale
Additional pertinent information: Provide additional pertinent information: prior therapy, disease stage, performance status, concurrent agents (names/doses/schedule)
Facility/dispensing info: Facility and/or doctor dispensing and administering medication: facility name, state, tax ID, address
Medication obtainment source: Select medication obtainment source: Accredo Specialty Pharmacy, Prescriber's office stock (billing on medical claim form), Retail pharmacy, Home Health/Home Infusion vendor, Other (specify)
Attestation and signature: Attestation and prescriber signature with date

The form lists example ophthalmic prostaglandins and other ophthalmic products and requires documented trials of covered alternatives and alternatives from other pharmacologic classes; for each trial include drug name, strength, dates taken, duration, documented results and any intolerances/adverse reactions.

Actions required of providers

Documentation Required

Document prior medication trials

Document that the patient has tried at least two ophthalmic prostaglandins OR two alternatives from different pharmacologic classes. For each agent include drug name, strength, dates taken, duration, documented outcome (efficacy) and any intolerances or adverse reactions.

At least two ophthalmic prostaglandins (examples: bimatoprost 0.03% or 0.01%, latanoprost 0.005%, travoprost 0.004%) — record drug name, strength, dates taken, duration, and outcomes/intolerances
Or two alternatives from different classes (e.g., beta-blocker, brimonidine, carbonic anhydrase inhibitor, netarsudil) — record drug name, strength, dates taken, duration, and outcomes/intolerances

Prior Authorization

Prior authorization submission

Submit the completed prior authorization form by fax or online; call for urgent requests to expedite.

Fax completed form to (855) 840-1678
Submit online at CoverMyMeds or via SureScripts in your EHR
For urgent requests call (800) 882-4462

Billing Rule

Prescriber's office stock billing option

If the medication is obtained from the prescriber's office stock, bill on a medical claim form; Accredo is Cigna's nationally preferred specialty pharmacy for dispensing.

Prescriber's office stock — billing on a medical claim form
Accredo is Cigna's nationally preferred specialty pharmacy (contact/ordering options provided on form)

Documentation Required

Ophthalmologist administration attestation

Complete the attestation indicating whether Durysta will be administered by or under the supervision of an ophthalmologist (select Yes or No).

Form requires attestation: Is the requested medication to be administered by, or under the supervision of an ophthalmologist? — Yes / No

Submission, dispensing, and facility details

Logistical fields capture the facility and/or doctor dispensing and administering the medication (facility name, state, tax ID, address). The form asks where the medication will be obtained with options including Accredo Specialty Pharmacy, Prescriber's office stock (billing on a medical claim form), Retail pharmacy, Home Health/Home Infusion vendor, or Other. The form concludes with an attestation and prescriber signature and date.

Fax (submit form)(855) 840-1678

Phone for urgent requests(800) 882-4462

Online portalsCoverMyMeds; SureScripts (submit via EHR)

Preferred specialty pharmacyAccredo Specialty Pharmacy