CurrentCignaPolicy v041525

Levoleucovorin (Fusilev) prior authorization coverage request form

This document is a Cigna prior-authorization/coverage request form governing requests for levoleucovorin (Fusilev) and related vial products for oncology and related indications, to be completed by prescribers and submitted to Cigna Pharmacy Services. It affects prescribers, dispensing facilities, and Cigna reviewers processing prior authorization for covered members.

Policy Summary

PayerCigna

PolicyLevoleucovorin (Fusilev) prior authorization coverage request form

Policy CodePolicy v041525

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the completed prior-authorization form (or submit online via CoverMyMeds/SureScripts) including diagnosis, medication details, and supporting clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

855-840-1678fax to submit

800-882-4462urgent phone

Accredopreferred specialty pharmacy

Coverage Criteria

Initial prior-authorization submission requirements

Coverage requests considered when ALL of the following information is provided:

Form completion: Completed patient and prescriber identifiers including required asterisked items

Required to process request

Medication details: Medication product, dose, quantity, duration, and directions must be specified

Supports dosing and duration review

Clinical indication and supporting info: Diagnosis selected from the listed oncology indications and additional pertinent information including prior therapy, disease stage, and performance status must be provided

Used to determine medical necessity for the requested indication

Policy Summary

PayerCigna

PolicyLevoleucovorin (Fusilev) prior authorization coverage request form

Policy CodePolicy v041525

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the completed prior-authorization form (or submit online via CoverMyMeds/SureScripts) including diagnosis, medication details, and supporting clinical information.

SourceLink

On This Page

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No explicit exclusions are listed on the prior‑authorization form for levoleucovorin (Fusilev). The form does not provide a separate exclusions section or enumerate conditions that would automatically preclude coverage; coverage determinations are made through review of the submitted clinical information.

The form does not enumerate specific Not Medically Necessary conditions. Whether a requested use is considered not medically necessary will depend on the clinical information provided with the request (diagnosis selection, prior therapy, disease stage, performance status and other supporting details) and subsequent clinical review.

Medication and Diagnosis Coding

Requested medication productsmixed

Fusilev 50 mg vial	Medication product option listed on form
levoleucovorin 10 mg/mL vial	Medication product option listed on form
levoleucovorin 175 mg vial	Medication product option listed on form

Diagnosis code fieldICD-10

ICD10

Field provided for diagnosis code entry

Provider Actions and Submission Requirements

Prior Authorization

Prior authorization required — submit completed form or use CoverMyMeds/SureScripts

Prior authorization is required for levoleucovorin/Fusilev requests; submit the completed form or submit online via CoverMyMeds or through SureScripts in your EHR to initiate review.

Note

Dispensing channel — specify where medication will be obtained (Accredo preferred)

Indicate where the medication will be obtained on the form. Accredo is identified as Cigna's nationally preferred specialty pharmacy; other options include prescriber's office stock (billed on a medical claim), retail pharmacy, or home infusion vendors.

Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy)
Prescriber's office stock (billing on a medical claim form)
Retail pharmacy
Home Health / Home Infusion vendor
Medication orders can be placed with Accredo via E-prescribe, fax, or verbal methods (contact details provided on form).

Documentation Required

Required documentation on form — patient, prescriber, medication, facility, and clinical details

Complete all required patient and prescriber identifiers and provide full medication and clinical details on the form to support medical necessity review.

Patient and prescriber identifiers: physician name, DEA/NPI or TIN, Cigna ID, patient date of birth, patient and office addresses, contact phone/fax
Medication details: product selection (Fusilev or levoleucovorin vial options), directions for use, dose, quantity, duration of therapy, and ICD-10 diagnosis code
Facility/dispensing details: facility name, state, tax ID, address, and whether medication is for a chronic/long-term condition
Clinical information: diagnosis selected from listed oncology indications and additional pertinent information including prior therapy, disease stage, performance status, and concurrent agents (names/doses/schedule)

Denial Risk

Incomplete form risk — missing required (*) items may prevent faxed response

Do not leave required asterisked (*) items incomplete; if asterisked items are not fully completed, Cigna may be unable to respond with the outcome via fax.

Background

Levoleucovorin (Fusilev) is included on the request form as a chemotherapeutic rescue and supportive agent for multiple oncology indications. The form lists a broad set of cancer diagnoses for which levoleucovorin may be requested (for example, Acute lymphoblastic leukemia (ALL), various lymphomas, colorectal and other solid tumor types), and asks providers to supply diagnosis selection and supporting clinical details to allow Cigna to assess medical necessity.

Definitions

levoleucovorin — definition and form-listed products

Generic namelevoleucovorin calcium

Brand name listed on formFusilev

Available vial presentations on formFusilev 50 mg vial; levoleucovorin 10 mg/mL vial; levoleucovorin 175 mg vial

Form usage fieldsDirections for use, Dose, Quantity, Duration of therapy, ICD10 diagnosis code