CurrentCignaPolicy v010124

Fluorouracil (Adrucil) injectable prior authorization form

This document is a Cigna prior authorization/coverage request form for injectable fluorouracil (Adrucil) vials; it governs submission requirements for providers requesting coverage and/or dispensing details for affected patients.

Policy Summary

PayerCigna

PolicyFluorouracil (Adrucil) injectable prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with medication strength, ICD-10 diagnosis, dosing, duration, and required patient and prescriber identifiers.

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

vial sizesavailable vial strengths

Coverage and Medical Necessity Requirements

Information required to evaluate medical necessity

Policy Summary

PayerCigna

PolicyFluorouracil (Adrucil) injectable prior authorization form

Policy CodePolicy v010124

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with medication strength, ICD-10 diagnosis, dosing, duration, and required patient and prescriber identifiers.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Basic submission requirements: Form must include completed asterisked patient and physician identifiers, medication requested (strength), ICD-10 diagnosis, dose/frequency/duration, patient height/weight, and prescriber attestation/signature.

supported by form fields

Diagnosis selection: Select applicable diagnosis from the provided list (e.g., colorectal cancer, head and neck cancer, gastric cancer, breast cancer, anal carcinoma, etc.) or specify other with supporting details.

diagnosis options listed on form

Clinical details for oncology uses: When relevant, indicate if drug is part of induction therapy (for head and neck cancer), provide disease stage, prior therapy, performance status, and concurrent agents with doses/schedules.

clinical information section

Indicate where the medication will be obtained by selecting one of the provided options. Choices include 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, or specify Other with details. If Accredo is selected, medication orders may be placed via e-prescribe, fax, or verbal order per Accredo’s contact procedures.

Provider Submission Requirements and Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for injectable fluorouracil. Complete all required fields on the form (including medication strength/vial size, ICD-10 diagnosis code, dose, frequency, and duration) to allow timely review.

Medication requested including specific vial size (e.g., 500mg/10mL, 1g/20mL, 2.5g/50mL, 5g/100mL)
ICD-10 code for the diagnosis
Dose, frequency, and duration of therapy

Note

Site of Care and Chronic Therapy

Indicate whether the patient is a candidate for home infusion and whether the physician has an in-office infusion site. Mark if the request is for a chronic or long-term condition that may require ongoing therapy.

Is the patient a candidate for home infusion? (Yes/No)
Does the physician have an in-office infusion site? (Yes/No)
Is the medication for a chronic/long-term condition? (Yes/No)

Documentation Required

Required Clinical and Administrative Information

Provide the required clinical and administrative information precisely as requested on the form. Include patient and prescriber identifiers and clinical details to support medical necessity.

Patient identifiers: Cigna ID, patient name, DOB, address, phone
Prescriber identifiers: Physician name, specialty, DEA/NPI/TIN, office contact, phone, fax, office address
Medication details: exact drug name and vial size, ICD-10, dose, frequency, duration
Clinical details: diagnosis (select from list or specify), pertinent staging/prior therapy/performance status, height and weight
If head and neck cancer: indicate if drug is part of induction therapy

Denial Risk

Incomplete Form Risk

Incomplete forms lacking any required asterisked items (for example: Cigna ID, physician DEA/NPI/TIN, patient name, DOB, medication strength, ICD-10, dose/frequency) may prevent a fax response and will impede or delay review. Ensure all fields marked with an asterisk are completed before submission.

Missing asterisked items may result in no faxed response
Complete all required fields to avoid delays in prior authorization review

Where Medication Will Be Obtained / Administered

Billing Rule

Specify infusion center / dispensing source and provide facility details

Indicate where the medication will be obtained and provide facility or dispensing details when applicable: options include Accredo Specialty Pharmacy (Cigna’s nationally preferred specialty pharmacy), prescriber’s office stock, retail pharmacy, or a Home Health/Home Infusion vendor.

Check the appropriate "Where will this medication be obtained?" box and, if applicable, supply the facility name, state, Tax ID#, and full address for the dispensing/administration site.
If using Accredo, note that Accredo is Cigna’s nationally preferred specialty pharmacy and orders can be placed via e-prescribe, fax, or verbal per the form instructions.

Ongoing / Long-Term Therapy Information

Continuation/long-term therapy information

For ongoing therapy, indicate chronic/long-term need and provide administration site and duration details.

Chronic therapy attestation: Physician must indicate if medication is for a chronic or long-term condition that may be necessary for the life of the patient.

checkbox on form

Site of care and administration details: Document whether patient is a candidate for home infusion and whether the physician has an in-office infusion site; provide facility/dispensing details (facility name, state, Tax ID, address) when medication will be obtained or administered in a facility or office setting.

site of care fields on form

Duration and ongoing use: Provide expected duration of ongoing therapy and any documentation supporting chronic need (e.g., disease course, prior response), plus confirm continued need at each authorization renewal.

supported by clinical information and chronic-therapy question

Step-Therapy / Access Considerations

Question	Response options / action required
Is the patient a candidate for home infusion?	Yes / No — provider must indicate whether the patient is a candidate for home infusion
Does the physician have an in‑office infusion site?	Yes / No — provider must indicate presence of an in‑office infusion site
Is the requested medication for a chronic or long‑term condition (may be necessary for the life of the patient)?	Yes / No — provider must indicate if medication is for chronic/long‑term therapy

Key Definitions

Induction therapy — definition

TermInduction therapy

Definition (form context)Whether the drug is being given as part of induction therapy for head and neck cancer (Yes/No).

When to indicateIf the requested fluorouracil is being administered as part of initial induction treatment for head and neck cancer, check the 'Yes' box on the clinical information section.

Supporting details requestedProvide additional pertinent information such as disease stage, prior therapy, performance status, and names/doses/schedules of any concurrent agents.

Attestation requirementPrescriber must sign and date the form attesting information is true and accurate; audit of medical information may be performed.

fluorouracil 500mg/10mL	listed vial strength
fluorouracil 1g/20mL	listed vial strength
fluorouracil 2.5g/50mL	listed vial strength
fluorouracil 5g/100mL	listed vial strength
Adrucil 500mg/10mL	listed vial strength (brand)
Adrucil 2.5g/50mL	listed vial strength (brand)
Adrucil 5g/100mL	listed vial strength (brand)

OpenPayer