CurrentCignaPolicy N/A

Tevimbra Prior Authorization Request Form

A Cigna prior authorization request form to collect clinical, demographic, dispensing, and site-of-care information for coverage review of Tevimbra (tislelizumab-jsgr) across multiple oncology indications and settings. It is an administrative form for submitting PA requests (standard or urgent) to Cigna/Accredo.

Policy Summary

PayerCigna

PolicyTevimbra Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online at covermymeds.com (complete all asterisked fields) or call (800) 882-4462 to expedite urgent requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

8Listed Indications on Form

5 business daysStandard response time

Policy summary & quick facts

A Cigna prior authorization request form to collect clinical, demographic, dispensing, and site-of-care information for coverage review of Tevimbra (tislelizumab-jsgr) across multiple oncology indications and settings. This is an administrative form for submitting PA requests (standard or urgent) to Cigna; Accredo is identified as Cigna's nationally preferred specialty pharmacy and the form captures alternative dispensing and infusion locations and billing considerations to support PA review.

Form collection and decision inputs

Form Collection / Decision Inputs

Fields and checkboxes the provider must complete to support prior authorization review

ALL of the following

Patient and provider identifiers
- Patient identifiers: Submit patient identifiers: Patient Name, Cigna ID, Date of Birth, Patient Street Address, Patient Phone
- Provider identifiers: Submit provider identifiers: Physician Name, Specialty, DEA, NPI or TIN, Office Contact Person, Office Phone, Office Fax, Office Street Address
Urgency: Indicate urgency: Standard OR Urgent (attestation required for urgent)
Medication specifics: Specify medication requested: Tevimbra 100 mg/10 mL vial; include Dose, Duration of Therapy, Frequency of therapy, J-Code, ICD10
Dispensing / administration location: Indicate dispensing/administration location: Accredo Specialty Pharmacy / Hospital Outpatient / Retail pharmacy / Other / Home Health / Physician's office stock
At least one diagnosis
- anal carcinoma
- CLL/SLL: chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) for histologic (Richter's) transformation to diffuse large B-cell lymphoma
- ESCC: esophageal squamous cell carcinoma (ESCC)
- G/GEJ: gastric or gastroesophageal junction adenocarcinoma (G/GEJ)
- Head and neck (nasopharynx): head and neck cancers of nasopharynx
Indication-specific questions (examples)
- ESCC
  - ESCC: unresectable or metastatic: Does the patient have unresectable or metastatic disease? (Yes/No)
  - ESCC: prior systemic chemo: Has the patient received prior systemic chemotherapy? (Yes/No)
  - ESCC: prior PD-(L)1: If yes, did prior chemo include a PD-(L)1 inhibitor? (Yes/No)
- HCC
  - HCC: only agent: Will this medication be the only one used at this time to treat the patient's disease? (Yes/No)
Additional requirements
- Additional clinical info: Provide Additional Pertinent Information including disease stage, prior therapy, performance status, and names/doses/admin schedule of any agents to be used concurrently
- Prescriber attestation signature and date required

What providers must do

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online at covermymeds.com or via SureScripts. Ensure all asterisked (*) fields are completed — including required patient and provider identifiers — because Cigna will not respond via fax unless those fields are filled.

Prior Authorization

Urgent request process

For urgent requests, call (800) 882-4462 to expedite processing. Be sure to select the Urgent attestation checkbox on the form to attest that applying the standard review time frame may seriously jeopardize the patient’s life, health, or ability to regain maximum function.

Documentation Required

Provide indication-specific clinical documentation

Provide indication‑specific clinical documentation with the request. Required clinical items include disease stage, prior therapies (including prior immunotherapy or PD‑(L)1 exposure where applicable), performance status, relevant molecular markers (for example MSI‑H, dMMR, POLE/POLD1, del(17p)/TP53), and the names/doses/administration schedule of any agents to be used concurrently.

Billing Rule

Dispensing and site-of-care selection

Indicate the dispensing and site‑of‑care selection on the form. Accredo is listed as Cigna’s nationally preferred specialty pharmacy. Other options captured include home infusion/home health, physician’s office stock (medical claim), hospital outpatient, retail pharmacy, or other settings. Note: some Cigna plans require infusion in the least intensive medically appropriate setting and a Specialty Care Options Case Manager may redirect the patient to an alternate setting.

Documentation Required

Attestation and audit consent

Prescriber attestation must be signed and dated on the form. The Health Plan or its designees may perform routine audits and request medical records to verify the accuracy of the information provided.

Definitions and additional notes

This administrative prior authorization form for Tevimbra (tislelizumab-jsgr) is used to collect required clinical and administrative data to support coverage decisions across multiple oncology indications (listed on the form). The form requires medication details (e.g., Tevimbra 100 mg/10 mL vial), diagnosis and indication-specific clinical information, and site-of-care selection. Accredo is Cigna's nationally preferred specialty pharmacy; the form also records alternative dispensing and administration sites (hospital outpatient, retail, home infusion, physician office stock) and includes notes about site-of-care and billing considerations (some plans require infusion in the least intensive medically appropriate setting and re-direction may be arranged with a Specialty Care Options Case Manager).

Urgent request: A request where applying the standard review time frame may seriously jeopardize the customer's life, health, or ability to regain maximum function; requires attestation and a phone call to expedite.

Policy Summary

PayerCigna

PolicyTevimbra Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online at covermymeds.com (complete all asterisked fields) or call (800) 882-4462 to expedite urgent requests.

SourceLink

On This Page

Anal carcinoma

Anal: only agent: Will this medication be the only one used at this time to treat the patient's disease? (Yes/No)
Anal: pre-op use: Will this medication be used prior to abdominoperineal resection? (Yes/No)
Anal: locally recurrent: Does your patient have locally recurrent, progressive disease? (Yes/No)
Anal: line of therapy: Is this medication being used as first-line therapy or preferred second-line and subsequent therapy? (First-line / Preferred second-line and subsequent / Neither or Unknown)
Anal: metastatic: Does your patient have metastatic disease? (Yes/No)
Anal: prior immunotherapy: Has the patient received prior immunotherapy? (Yes/No)

Head and neck (nasopharynx)

H&N: only agent: Will this medication be the only one used at this time to treat the patient's disease? (Yes/No)
H&N: combo cisplatin/gemcitabine: Is/Will this medication be used in combination with cisplatin and gemcitabine? (Yes/No)
H&N: performance status: Performance status (PS 0/1/2/3/4/Unknown)
H&N: oligometastatic: Does the patient have oligometastatic disease? (Yes/No)
H&N: widely metastatic: Does your patient have widely metastatic disease? (Yes/No)

Small bowel adenocarcinoma

Small bowel: only agent: Will this medication be the only one used at this time to treat the patient's disease? (Yes/No)
Small bowel: MSI-H or dMMR: Does your patient have MSI-H or dMMR disease? (Yes/No)
Small bowel: POLE/POLD1: Does your patient have POLE/POLD1 mutation with ultra-hypermutated phenotype (e.g., TMB >50 mut/Mb)? (Yes/No)
Small bowel: intended use: How is this drug being used? (primary treatment for locally unresectable or medically inoperable disease / advanced or metastatic disease / Neither or Unknown)
Small bowel: prior checkpoint inhibitor: Has the patient received previous treatment with a checkpoint inhibitor, for any line of therapy? (Yes/No)

G/GEJ

G/GEJ: combo chemo: Is/Will this medication be used in combination with platinum and fluoropyrimidine-based chemotherapy? (Yes/No)
G/GEJ: first-line: Is this medication being prescribed as first-line treatment? (Yes/No)
G/GEJ: unresectable or metastatic: Does your patient have unresectable or metastatic disease? (Yes/No)
G/GEJ: HER2-negative: Does your patient have HER2-negative disease? (Yes/No)
G/GEJ: PD-L1 expression: Does your patient have tumors that express PD-L1? (Yes/No)

OpenPayer

Tevimbra Prior Authorization Request Form

Policy summary & quick facts

Form collection and decision inputs

Medication and claim coding fields

What providers must do

Definitions and additional notes

Document changes and history

J-Code	Provider to supply appropriate J-code as entered on the form
ICD10	Provider to supply applicable diagnosis code as entered on the form