CurrentCignaPolicy N/A

Tecvayli (teclistamab-cqyv) prior authorization for multiple myeloma

Form and prior authorization instructions for coverage review of Tecvayli (teclistamab-cqyv), primarily for patients with multiple myeloma; intended for prescribers and site-of-care planners submitting requests to Cigna. Applies to Cigna members nationally unless local plan states differ.

Policy Summary

PayerCigna

PolicyTecvayli (teclistamab-cqyv) prior authorization for multiple myeloma

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Tecvayli prior authorization form with required patient/provider identifiers and attach chart notes documenting diagnosis, prior lines of therapy, and prior exposure to key myeloma drug classes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

2vial presentations

Accredopreferred specialty pharmacy

Urgent lineurgent phone

Coverage Criteria for Tecvayli (teclistamab-cqyv)

Information required for medical necessity review

Coverage assessment collects the following information to determine medical necessity for Tecvayli in multiple myeloma:

Baseline administrative and clinical data: Provider must submit completed form with all required patient and provider identifiers and attach supportive documentation (chart notes).

See documentation module

Diagnosis and disease status: Indicate diagnosis (Multiple Myeloma or other) and whether disease is relapsed or refractory.

Prior therapy exposure: Document number of prior lines of therapy and prior treatments including proteasome inhibitors (e.g., bortezomib, carfilzomib, ixazomib), immunomodulatory agents (e.g., thalidomide, lenalidomide, pomalidomide), and anti-CD38 monoclonal antibodies (e.g., daratumumab, isatuximab).

Form includes checkboxes for prior exposure to these classes.

Policy Summary

PayerCigna

PolicyTecvayli (teclistamab-cqyv) prior authorization for multiple myeloma

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Per the form, site-of-care must be specified for Tecvayli administration and procurement. The form asks where the drug will be administered (home, physician office, hospital outpatient, or other) and where the medication will be obtained (e.g., Accredo, retail, hospital outpatient).

The policy notes that, per some Cigna plans, infusion of medication MUST occur in the least intensive, medically appropriate setting. Providers are asked whether the patient is a candidate for redirection to an alternate, lower‑intensity setting (for example, home or physician office) and whether the patient is a candidate for home infusion. The form also captures whether the physician has an in‑office infusion site to support planning.

Plan‑level site‑of‑care restrictions should be considered when submitting requests: if a lower‑intensity, medically appropriate setting is available, higher‑intensity settings may be excluded by the plan. Document the medical necessity rationale on the form when declining redirection or home infusion so coverage review can consider site‑of‑care constraints.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for Tecvayli. Use the Cigna prior authorization form when submitting requests and include all required clinical documentation to support medical necessity.

Affected product: Tecvayli (teclistamab-cqyv)

Documentation Required

Supportive Documentation Required

This request requires supportive documentation (for example: chart notes, diagnosis details, prior therapy records, stage, performance status). Requests submitted without the required supporting documentation may be delayed or denied.

Attach chart notes, prior therapy records, and other relevant medical documentation
Incomplete requests lacking supportive documentation are at risk for denial

Note

Form Clinical Questions — Relapsed/Refractory Status and Prior Therapies

The authorization form asks whether the diagnosis is relapsed or refractory multiple myeloma and the number of prior lines of therapy. Answer these questions and provide specifics on prior exposures (proteasome inhibitors, immunomodulatory agents, anti‑CD38 antibodies) as requested on the form.

Indicate if disease is relapsed or refractory
Specify number of prior therapy lines and prior exposures (e.g., bortezomib, carfilzomib, ixazomib; lenalidomide, thalidomide, pomalidomide; daratumumab, isatuximab)

Note

Provider Actions — Complete Clinical and Administrative Details

The form also requests additional clinical details such as disease stage, prior therapy names/doses/schedules, performance status, and prescriber information. Be sure to complete attestation and include prescriber signature/date. Submissions can be made online via CoverMyMeds or through SureScripts in the EHR to expedite review.

Provide disease stage, performance status, and concurrent therapy details
Complete attestation and prescriber signature/date
Submit via CoverMyMeds or SureScripts to save time

Background

Tecvayli (teclistamab‑cqyv) is a BCMA‑directed therapy requested for the treatment of multiple myeloma. The prior authorization form is used to collect essential clinical and administrative information to determine medical necessity for Tecvayli in this indication.

Specifically, the form captures the patient’s diagnosis (e.g., Multiple Myeloma), whether disease is relapsed or refractory, the number of prior lines of therapy, and prior exposure to key myeloma drug classes (proteasome inhibitors, immunomodulatory agents, and anti‑CD38 monoclonal antibodies). This information supports assessment of treatment sequencing and eligibility for coverage.

Key Definitions

Relapsed or refractory disease — provider must indicate status and number of prior therapy lines; used to assess eligibility

Relapsed vs. refractory statusProvider must indicate whether the patient with Multiple Myeloma has relapsed or refractory disease (Yes or No).

Number of prior therapy linesSpecify how many prior lines of therapy were used for this diagnosis: None, One, Two, Three, or Four or more.

Prior exposure — proteasome inhibitorDocument prior treatment with a proteasome inhibitor (examples listed on form: bortezomib/Velcade, carfilzomib/Kyprolis, ixazomib/Ninlaro).

Prior exposure — immunomodulatory agent (IMiD)Document prior treatment with an IMiD (examples listed on form: thalidomide/Thalomid, lenalidomide/Revlimid, pomalidomide/Pomalyst).

Prior exposure — anti‑CD38 monoclonal antibodyDocument prior treatment with an anti‑CD38 antibody (examples listed on form: daratumumab/Darzalex, Darzalex Faspro, isatuximab/Sarclisa).

Initial Authorization Data Elements

Initial authorization data elements

Information requested for initial authorization

Diagnosis: Indicate MM diagnosis and whether relapsed/refractory.

Prior lines of therapy: Specify number of prior therapy lines (None, One, Two, Three, Four or more).

Prior drug class exposure: Document prior treatment with a proteasome inhibitor, an immunomodulatory agent (IMiD), and an anti-CD38 monoclonal antibody as applicable (Yes/No).

Supportive clinical details: Provide additional information including disease stage, prior therapy details, performance status, and names/doses/schedules of concurrent agents.

Attach chart notes or other supporting documentation to the request.

Prior Therapy and Therapeutic Sequencing

Information requested	Response options
Does the patient have relapsed or refractory disease (if MM)?	Yes / No (checkbox)
Number of prior lines of therapy for this diagnosis	None / One / Two / Three / Four or more (checkboxes)
Prior exposure to proteasome inhibitor (examples: bortezomib, carfilzomib, ixazomib)	Yes / No (checkbox)
Prior exposure to an immunomodulatory agent (IMiD) (examples: thalidomide, lenalidomide, pomalidomide)	Yes / No (checkbox)
Prior exposure to an anti-CD38 monoclonal antibody (examples: daratumumab, isatuximab)	Yes / No (checkbox)
Attach supportive documentation	Chart notes including disease stage, prior therapy, performance status, names/doses/schedules of concurrent agents

Site of Care and Dispensing

Note

Specify procurement and administration site; Accredo preferred

Designate where the medication will be obtained and where it will be administered on the form; note that Accredo is listed as Cigna's nationally preferred specialty pharmacy.

Select procurement site: Accredo Specialty Pharmacy, Hospital Outpatient, Retail, Home Health/Home Infusion, Physician's office stock, or Other.
Select administration site: Patient's Home, Physician's Office, Hospital Outpatient, or Other.
Per some Cigna plans, infusion must occur in the least intensive, medically appropriate setting; indicate candidacy for redirection or home infusion.

OpenPayer

Tecvayli (teclistamab-cqyv) prior authorization for multiple myeloma

Coverage Criteria for Tecvayli (teclistamab-cqyv)

Billing and Diagnosis Codes

What Providers Must Do

Background

Key Definitions

Initial Authorization Data Elements

Prior Therapy and Therapeutic Sequencing

Site of Care and Dispensing