CurrentCignaPolicy N/A

Etoposide (Etopophos/Toposar) prior authorization form

This document is a Cigna prior authorization request form governing coverage determinations for intravenous etoposide formulations (including Etopophos and Toposar) for Cigna members; it describes what information providers must submit to request coverage and where to send the request.

Policy Summary

PayerCigna

PolicyEtoposide (Etopophos/Toposar) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form with required clinical details by fax to (855) 840-1678 or online to request coverage; use the urgent phone number for expedited review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

(855) 840-1678fax

(800) 882-4462urgent phone

Accredopreferred specialty pharmacy

Coverage Criteria for Intravenous Etoposide

Prior Authorization / Medical Necessity Determination

Coverage consideration is based on the diagnosis selected on the form and supporting clinical information; providers must attest and supply required identifiers and clinical rationale.

Form submission requirements: Completed patient and provider identifiers (all asterisked fields), selected medication formulation, ICD-10 diagnosis, dosing/frequency/duration, height/weight, diagnosis checkbox or free-text diagnosis, and clinical justification including disease stage, prior therapies and performance status must be provided.

Supports medical necessity review.

Diagnosis selection: Requester must select the applicable diagnosis from the provided extensive list (examples include leukemias, lymphomas, sarcomas, CNS tumors, breast cancer, lung cancer, and many others) or, if 'None of the above' is checked, provide the patient's diagnosis or reason for treatment.

Diagnosis selection drives clinical adjudication.

Disease-specific questions:

Policy Summary

PayerCigna

PolicyEtoposide (Etopophos/Toposar) prior authorization form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form with required clinical details by fax to (855) 840-1678 or online to request coverage; use the urgent phone number for expedited review.

SourceLink

On This Page

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When applicable, complete the disease-specific items: if diffuse large B-cell lymphoma (DLBCL), indicate whether etoposide is being given as part of R-CHOP-14; if breast cancer, indicate whether treating brain metastases; if adult gliomas, confirm patient age >= 18 years.

These details are required for reviewers to assess regimen appropriateness.

The form lists a comprehensive set of potential diagnoses for which intravenous etoposide (Etopophos/Toposar) may be requested, including hematologic malignancies (for example, Acute Lymphoblastic Leukemia, Acute Myeloid Leukemia, Diffuse Large B‑Cell Lymphoma, CLL/SLL, Mantle Cell Lymphoma, Hodgkin’s lymphoma), a broad range of solid tumors and central nervous system cancers (for example, breast cancer, neuroendocrine tumors, non‑small cell lung cancer, ovarian/fallopian tube/peritoneal cancer, adult gliomas, medulloblastoma), sarcomas and pediatric tumors (for example, Ewing sarcoma, osteosarcoma, neuroblastoma, Wilms tumor), and numerous other listed indications. The form also includes a None of the above option with a prompt to provide the specific patient diagnosis or reason for treatment when an unlisted diagnosis applies.

The form does not specify explicit conditions that are automatically considered not medically necessary. Instead, coverage decisions are made through prior authorization review based on the completeness and quality of the clinical information submitted. Requests may be denied or not approved if the required clinical details (for example, disease stage, prior therapies, performance status, concurrent agents with names/doses/schedules, and the prescriber attestation/signature) are not provided or if, upon review, the clinical justification fails to meet the plan’s internal medical‑necessity criteria.

Diagnosis / Procedure Codes Requested

Diagnosis Codes (requested)ICD-10

ICD10

ICD-10 diagnosis code to be provided by requester

Regimens and Contexts Noted on Form

Regimen	Indication / notes
R-CHOP-14	Diffuse large B-cell lymphoma — form asks whether the requested etoposide is being given as part of the R-CHOP-14 treatment for DLBCL; requester must indicate Yes or No and provide supporting clinical information (disease stage, prior therapy, performance status, concurrent agents).

What Providers Must Do to Request Coverage

Prior Authorization

Prior Authorization Required

Prior authorization is required for all etoposide formulations listed on the request form. Submit a completed prior authorization form with the required clinical information by fax or online. Our standard response time for prescription drug coverage requests is 5 business days; if the request is urgent, call to expedite.

Affected products: etoposide vials (20 mg/mL: 5 mL, 25 mL, 50 mL), Etopophos 100 mg vial, Toposar 20 mg/mL (5 mL, 25 mL, 50 mL)
Submission pathways: Fax, online at www.covermymeds.com/main/prior-authorization-forms/cigna/, or via SureScripts in your EHR
Standard response time: 5 business days; call for urgent requests

Note

Preferred Specialty Pharmacy

Cigna's nationally preferred specialty pharmacy for these medications is Accredo; however, other dispensing sources are allowed including prescriber's office stock (billed on a medical claim), retail pharmacy, or home health/home infusion vendors. Medication orders can be placed with Accredo via E-prescribe (NCPDP 4436920), fax, or verbal order.

Preferred specialty pharmacy: Accredo Specialty Pharmacy (1620 Century Center Pkwy, Memphis, TN 38134-8822 | NCPDP 4436920)
Accredo contact: Fax 888.302.1028; Verbal 866.759.1557
Other permitted sources: Prescriber's office stock (medical claim), Retail pharmacy, Home Health/Home Infusion vendor

Documentation Required

PROVIDER ACTIONS — Required Submission Data

Provider must supply required patient and prescriber identifiers and full medication details when submitting the prior authorization request. Failure to complete all asterisked (*) items on the form will prevent Cigna from responding via fax and may delay or preclude approval.

Required patient identifiers: Patient Name, Cigna ID, Date of Birth, Patient Street Address, Patient Phone
Required prescriber identifiers: Physician Name, Specialty, DEA, NPI or TIN, Office Contact Person, Office Phone, Office Fax, Office Street Address
Required medication details: Medication Requested (select specific etoposide formulation), ICD-10, Dose, Frequency, Duration, Patient height and weight, Clinical rationale and supporting information

Drug Formulations Listed

Etoposide formulations listed on form

Form-listed IV etoposide vial productsetoposide 20mg/mL (5 mL, 25 mL, 50 mL)

Etopophos formulationEtopophos 100 mg vial

Toposar formulationsToposar 20mg/mL (5 mL, 25 mL, 50 mL) vials

Most actionable itemWhen requesting prior authorization, specify the exact etoposide formulation and vial size selected from the form (e.g., Etopophos 100 mg vial or Toposar/etoposide 20 mg/mL — 5, 25, or 50 mL), and provide dose, frequency, and duration.

Line of Therapy Considerations

Line of Therapy

Line of therapy: The form requests prior therapy information to support the requested use but does not encode explicit line-of-therapy categories; reviewers will use the supplied prior therapy history and clinical justification to determine the appropriate line of therapy.

Provide prior treatments and dates on the form to assist adjudication.

Background

Etoposide (Etopophos/Toposar) is an intravenous cytotoxic chemotherapeutic agent used across a wide range of malignancies; the prior‑authorization form asks providers to select the applicable tumor type and supply supporting clinical details to establish medical necessity. The form includes disease‑specific questions when relevant (for example, whether etoposide is being given as part of R‑CHOP‑14 for Diffuse Large B‑Cell Lymphoma, whether it is used for brain metastases in breast cancer, and confirmation of age ≥18 for adult gliomas) and requests staging, prior therapy, performance status, and concurrent regimen information to guide the coverage determination.