Tysabri start form pdf 2026

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The document is a CIGNA HealthCare Prior Authorization Form for the medication Tysabri, used to treat conditions like multiple sclerosis and Crohn's disease. It outlines required provider and patient information, clinical details necessary for approval, and instructions for submission. The form emphasizes the importance of completing all sections to avoid delays in processing.
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  1. Click ‘Get Form’ to open the tysabri start form PDF in the editor.
  2. Begin by filling out the 'Provider Information' section. Enter your name, specialty, DEA or TIN, office contact person, and contact details.
  3. Next, complete the 'Patient Information' section. Input the patient's name, CIGNA ID, date of birth, and address details. Ensure all asterisked (*) fields are filled for compliance.
  4. In the 'Medication Requested' section, specify Tysabri along with strength & dose, J-Code, and quantity per month. Indicate where the medication will be obtained.
  5. Provide clinical information regarding the patient's diagnosis. Answer questions related to multiple sclerosis (MS) or Crohn’s disease (CD) as applicable.
  6. Review all entered information for accuracy before submitting. Once completed, save your changes and follow instructions to fax or submit online.

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To prepare the solution, withdraw 15 mL of TYSABRI concentrate from the vial using a sterile needle and syringe. Inject the concentrate into 100 mL 0.9% Sodium Chloride. No other intravenous diluents may be used to prepare the TYSABRI solution. Gently invert the TYSABRI solution to mix completely.
HOW LONG CAN I STAY ON TYSABRI? You may be treated with TYSABRI for as long as you and your healthcare team decide it is right for you. In the US, more than 40% of people being treated with TYSABRI have been using it for more than 5 years.
The TOUCH Prescribing Program is designed to: Inform prescribers, infusion center healthcare providers, and patients about the risk of progressive multifocal leukoencephalopathy (PML) associated with TYSABRI including the increased risk of PML with treatment duration and prior immunosuppressant use.
by Drugs.com For people with MS, some response is noted at 12 weeks, but it may take up to 2 years for the full effects to be seen. People with Crohns disease should discontinue Tysabri if there is no benefit after 12 weeks.
Efficacy maintained over 2 years By 69% in the overall population (RR of TYSABRI/placebo was 0.31 [95% CI 0.19-0.5])

starter form

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Natalizumab (TYSABRI)

VITAL SIGNS Obtain vital signs before start of Natalizumab infusion and at end of infusion. 3. Do not need lab results of CBC + Diff and/or CMP to start

Learn more
Tysabri (natalizumab) - accessdata.fda.gov

Review the TOUCH Prescriber/Patient Enrollment form for TYSABRI with the patient Read the Medication Guide given to you before you start TYSABRI and before

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