CurrentCignaPolicy N/A

prior_authorization_form

This document is a Cigna prior authorization request form to be completed by prescribers when requesting coverage/authorization for Tepylute (thiotepa) vials across care settings. It collects patient, prescriber, diagnosis, clinical-use details, administration site, pharmacy source, and regimen-specific checkboxes to support review.

Policy Summary

PayerCigna

Policyprior_authorization_form

Policy CodePolicy N/A

Change TypeInformational form (no material change)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; urgent requests require provider call to (800) 882-4462.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified for this form-based prior authorization document.

1Form version identifier

5 business daysStandard response time

Policy overview

This is a Cigna prior authorization form (v110125) for Tepylute (thiotepa). The form is used to collect patient and prescriber identifying information, the specific medication requested (Tepylute 100mg/10mL or 15mg/1.5mL vials), the ICD‑10 diagnosis, intended frequency and duration of therapy, J‑Code, source of medication and administration setting, facility/dispensing details (including tax ID for medical-claim billing), and regimen‑specific clinical information (transplant conditioning, CNS lymphoma, leptomeningeal metastases, prior therapies, CSF cytology, KPS and other branching items) to support Cigna's medical authorization review.

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Form-supplied clinical branching questions

Form-supplied clinical branching questions for authorization review

Complete applicable branching questions; answers inform clinical review but do not by themselves state coverage rules:

Patient and prescriber identifying information must be provided for review (Physician Name, Specialty, DEA/NPI/TIN, Patient Name, Cigna ID, DOB, Addresses, Contact info).

Asterisked items are required for fax response.

Select urgency: Standard or Urgent (attestation required for Urgent).

Specify medication requested: Tepylute 100mg/10ml vial or Tepylute 15mg/1.5mL vial.

Provide ICD-10 diagnosis and intended frequency and duration of therapy and J-code.

Indicate source of medication (Accredo Specialty Pharmacy, Hospital Outpatient, Retail, Home Health/Home Infusion vendor, Physician office stock, Other).

Accredo is Cigna's nationally preferred specialty pharmacy; contact details provided.

Identify facility/doctor dispensing and administering medication (facility name, tax ID, address).

Specify administration location (Patient's Home, Physician's Office, Hospital Outpatient, Other).

Per some Cigna plans, infusion must occur in the least intensive, medically appropriate setting; question on candidate for re-direction to alternate setting with Specialty Care Options Case Manager.

Diagnosis (ONE or more)

Leptomeningeal metastases pathway

Is the medication used as primary treatment? Yes/No
If no: used as maintenance treatment? Yes/No
If primary treatment: does patient have good risk status (KPS >= 60, no major neurologic deficits, minimal systemic disease, reasonable systemic options)? Yes/No
If maintenance: does patient have negative CSF cytology? Yes/No
If not negative CSF: is patient clinically stable with persistently positive CSF cytology? Yes/No

Primary CNS lymphoma pathway

Is medication used as induction therapy in combination with high-dose methotrexate, cytarabine, and rituximab? Yes/No
If no: used as consolidation therapy in a patient who had CR or CRu to induction therapy? Yes/No
If consolidation and yes: is it component of cytarabine and thiotepa followed by carmustine and thiotepa as high-dose systemic therapy with stem cell rescue? Yes/No
If no: is it component of TBC (thiotepa, busulfan, cyclophosphamide) regimen as high-dose systemic therapy with stem cell rescue? Yes/No
If not being used as consolidation after CR/CRu: is it used as treatment with autologous stem cell reinfusion for recurrent disease in eligible patient? Yes/No
If yes: does the patient have relapsed or refractory disease? Yes/No

Attestation and prescriber signature/date required verifying accuracy and consenting to possible audit.

attestation/signature

What providers must do

Prior Authorization

Submit prior authorization request

Fax the completed form or submit online; urgent requests must be phoned in. You can fax the completed prior authorization form to the number below or submit electronically via CoverMyMeds or SureScripts. If the request is urgent, the provider must call the urgent phone number to expedite the request.

Fax: (855) 840-1678
Submit online: CoverMyMeds or SureScripts
Urgent call: (800) 882-4462

Documentation Required

Complete required clinical fields and asterisked items

Complete all asterisked patient and prescriber fields so Cigna can respond via fax and support medical review. Required identifiers include prescriber DEA/NPI/TIN, physician name, patient name, Cigna ID, and date of birth. The form also requires the prescriber’s attestation and signature/date.

Physician Name
DEA, NPI or TIN
Patient Name
Cigna ID
Date of Birth
Prescriber attestation and signature/date

Billing Rule

Specify medication source and administration setting

Indicate where the medication will be obtained and where it will be administered. The form notes Accredo as Cigna’s nationally preferred specialty pharmacy and provides Accredo contact options. If billing on a medical claim, provide the facility/doctor dispensing information including facility name, address and Tax ID for medical-claim billing.

Acceptable sources: Accredo Specialty Pharmacy, Hospital Outpatient, Retail, Home Health/Home Infusion vendor, Physician office stock, Other
Administration locations: Patient's Home, Physician's Office, Hospital Outpatient, Other
Provide facility/doctor dispensing details and Tax ID for medical-claim billing

Documentation Required

Regimen-specific justification required

For transplant, CNS lymphoma, leptomeningeal metastases and other indications, indicate the exact regimen combinations and prior therapies, CSF cytology status, performance status (KPS), and whether generic thiotepa or Tepadina were tried or are unavailable. These regimen-specific data elements are required to support clinical review and the applicable branching questions on the form must be completed.

Specific regimen combinations (e.g., fludarabine + busulfan; fludarabine + melphalan; carmustine/TEAM/TBC etc.)
Prior therapies and prior whole brain radiation or high-dose methotrexate history
CSF cytology status (negative, persistently positive, or not)
Karnofsky Performance Status (KPS) or equivalent
Whether generic thiotepa or Tepadina were tried or cannot be used

Form logistics and operational notes

Operational summary

Form version identifier1

Standard response time5 business days

Submission fax number (prior auth form)(855) 840-1678

Urgent request phone(800) 882-4462

Accredo specialty pharmacy preferenceAccredo is Cigna's nationally preferred specialty pharmacy; Accredo order options include e-prescribe, Fax 888.302.1028, Verbal 866.759.1557

Scope summaryThis Cigna prior authorization form is to be completed by prescribers requesting coverage/authorization for Tepylute (thiotepa) vials across care settings; it collects patient and prescriber identifiers, diagnosis, clinical-use details, administration site, pharmacy source, and regimen-specific checkboxes to support review.

This is an informational prior authorization form: completion of the form provides the clinical and administrative information that informs Cigna's medical review but does not by itself establish coverage rules or guarantee coverage decisions.

Providers must complete all asterisked required fields for Cigna to respond via fax and to support review, and attest to the accuracy of the information with prescriber signature and date; urgent requests require attestation and a phone call to the urgent number noted on the form.

OpenPayer

prior_authorization_form

Policy overview

Form-supplied clinical branching questions

Codes referenced on form

What providers must do

Form logistics and operational notes

Revision history