CurrentCignaPolicy v010124

Trelstar (triptorelin) prior authorization request form

This document is a Cigna prior authorization request form for triptorelin (brand: Trelstar) injectable vials, intended for providers to request coverage and supply administrative and clinical information; it applies to Cigna members (national) but contains a national specialty pharmacy preference and administrative instructions.

Policy Summary

PayerCigna

PolicyTrelstar (triptorelin) prior authorization request form

Policy CodePolicy v010124

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with all required (*) patient and prescriber fields, diagnosis, medication strength, directions, and attestation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3available vial strengths listed

5 business daysstandard response time

855-840-1678fax

800-882-4462phone (urgent)

Prior Authorization / Coverage Criteria

Prior authorization submission criteria

Form-based prior authorization: coverage is considered when the provider submits complete clinical and administrative information via this form.

Form completion requirements: Provider completes all required asterisked (*) patient and prescriber fields, supplies diagnosis (ICD-10), selects medication strength, provides directions (dose, quantity, duration), and attests to accuracy.

Referenced in form instructions and attestation.

Medication requested: Provider selects the requested Trelstar vial strength (3.75 mg, 11.25 mg, or 22.5 mg) or specifies other and enters the ICD-10 diagnosis.

Medication and ICD-10 captured in Medication requested section.

Clinical support: Provider indicates patient's diagnosis (e.g., prostate cancer or other), documents whether the patient has advanced disease (Yes/No), and supplies additional clinical information including relevant labs or notes.

Policy Summary

PayerCigna

PolicyTrelstar (triptorelin) prior authorization request form

Policy CodePolicy v010124

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed prior authorization form with all required (*) patient and prescriber fields, diagnosis, medication strength, directions, and attestation.

SourceLink

On This Page

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Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization Required

Prior Authorization Required: This completed form is a request for prior authorization for Trelstar (triptorelin) injectable vials. Include the medication strength requested (3.75 mg, 11.25 mg, or 22.5 mg), ICD-10 diagnosis code, dosing (dose and directions), quantity, and duration of therapy. Incomplete or missing fields may delay or prevent authorization.

Medication strengths: Trelstar 3.75 mg, 11.25 mg, 22.5 mg, or specify other.
Required clinical fields: ICD-10, dose/directions, quantity, duration of therapy.

Note

Site-of-Care Consideration

Site-of-care: Indicate where the drug will be obtained and where it will be administered. Per some Cigna plans, infusion/administration MUST occur in the least intensive, medically appropriate setting. If the patient could be redirected (for example to physician office, home infusion, or alternate infusion site) with assistance from a Specialty Care Options Case Manager, indicate "Yes" or provide medical necessity rationale if "No." Failure to document site-of-care considerations may affect coverage or direct the member to a preferred site.

Where obtained: Accredo Specialty Pharmacy (preferred), hospital outpatient, retail, physician office stock (medical claim), home health/home infusion, or other.
Where administered: patient home, physician office, hospital outpatient, or other.
Note: Accredo contact options provided for specialty pharmacy orders.

Documentation Required

Required Documentation

Required Documentation: Complete all patient and prescriber fields marked with an asterisk (*) and provide diagnosis and supporting clinical information. Include specific directions (dose, quantity, duration), relevant clinical notes (disease status, labs, prior therapies), facility/provider dispensing information if applicable, and attestation/signature. Missing documentation may result in denial or delayed review.

Patient/prescriber fields required: Physician name, specialty, DEA/NPI/TIN, office contact, patient name, Cigna ID, date of birth, patient address, patient phone.
Clinical information required: ICD-10 diagnosis, advanced disease status, relevant labs and additional clinical information supporting medical necessity.
Dispensing/administration info: Where obtained, facility name, state, tax ID, address; where administered (home, physician office, hospital outpatient).
Attestation: Prescriber signature and date.

Denial Risk

Incomplete Form May Impede Response

Incomplete Form May Impede Response: Due to privacy regulations, Cigna cannot respond via fax with the outcome unless all asterisked (*) demographic and required fields on this form are completed. Ensure all required (*) items are filled to avoid delays; if urgent, call to expedite and consider submitting via CoverMyMeds or SureScripts in your EHR.

Privacy note: Fax responses are restricted if required fields are missing.
Submit options: www.covermymeds.com or SureScripts; standard response time is 5 business days—call for urgent requests.

Acquisition and Administration Location

Note

Specify obtainment and administration site (home | office | infusion center | hospital outpatient)

Indicate both where the medication will be obtained and where it will be administered; some plans require infusion in the least intensive, medically appropriate setting and may require redirection with case manager involvement.

Select obtainment site (Accredo Specialty Pharmacy is Cigna’s nationally preferred specialty pharmacy)
Select administration site (patient's home, physician's office, hospital outpatient, or other)
Answer whether patient is a candidate for redirection to an alternate infusion setting with a Specialty Care Options Case Manager

Trelstar 3.75 mg vial	Medication strength option listed on form
Trelstar 11.25 mg vial	Medication strength option listed on form
Trelstar 22.5 mg vial	Medication strength option listed on form

OpenPayer

Trelstar (triptorelin) prior authorization request form

Prior Authorization / Coverage Criteria

Requested Medication Options / Codes

Provider Actions & Submission Instructions

Acquisition and Administration Location