CurrentCignaPolicy v031526

Imfinzi (durvalumab) patient information / prior authorization form

This document is a Cigna patient information and prior authorization form for Imfinzi (durvalumab), used to collect clinical, demographic, and treatment details from prescribers to support coverage and dispensing decisions. It affects prescribers, infusion sites, specialty pharmacies, and Cigna pharmacy/medical review staff.

Policy Summary

PayerCigna

PolicyImfinzi (durvalumab) patient information / prior authorization form

Policy CodePolicy v031526

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization/patient information form via fax (855-840-1678) or online; urgent requests should also be called in.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20document chunks parsed

15+diagnoses listed

2vial presentations

5 business daysstandard response time

Coverage Criteria and Required Supporting Information

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.

Indication-specific supporting criteria

Coverage assessment will be based on indication-specific information; the form captures the following sets of required supporting facts:

Indication selection: Provider must select the diagnosis from the form list (e.g., Ampullary adenocarcinoma; Biliary tract cancer; Endometrial cancer; Esophageal/EGJ carcinoma; Gastric carcinoma; GC/GEJC; Hepatocellular carcinoma; Non-small cell lung cancer; Small cell lung cancer; Small cell neuroendocrine carcinoma of the cervix; Urothelial carcinoma; Muscle invasive bladder cancer)

Selection triggers the relevant follow-up question block on the form

Ampullary adenocarcinoma details: Describe disease status (metastatic at presentation, Stage IV resected, unresectable localized, or other); confirm ECOG 0–1 with good biliary drainage and adequate nutrition; indicate if being used first-line in combination with gemcitabine + cisplatin

Biliary tract cancer (BTC): Indicate whether durvalumab is given in combination with gemcitabine + cisplatin and whether disease is locally advanced or metastatic

Endometrial cancer: State if given with carboplatin + paclitaxel followed by single-agent durvalumab; document primary advanced or recurrent disease and whether tumor is dMMR

Esophageal / Esophagogastric junction carcinoma: Document fitness for surgery, MSI‑H/dMMR status, and whether durvalumab will be used with tremelimumab

Gastric carcinoma: Document fitness for surgery, MSI‑H/dMMR status, and whether durvalumab will be used with tremelimumab

GC/GEJC (FLOT regimen): Indicate if durvalumab will be used with FLOT (fluorouracil, leucovorin, oxaliplatin, docetaxel) as neoadjuvant/adjuvant therapy followed by single‑agent durvalumab

Hepatocellular carcinoma (HCC): Confirm unresectable disease and indicate whether durvalumab will be used in combination with tremelimumab‑actl

Non‑small cell lung cancer (NSCLC): Indicate resectable vs unresectable status; document locally advanced/unresectable disease, progression after chemoradiotherapy, tumor size/node positivity (e.g., ≥4 cm and/or node positive), EGFR and ALK status, and whether planned as neoadjuvant platinum‑containing chemotherapy followed by adjuvant single‑agent durvalumab

Small cell lung cancer (SCLC): Document stage (extensive vs limited), whether used as part of first‑line therapy, and if combined with etoposide plus carboplatin or cisplatin for the first 4 cycles

Small cell neuroendocrine carcinoma of the cervix (NECC): Indicate use in combination with carboplatin or cisplatin plus etoposide and confirm metastatic, persistent, or recurrent disease status

Urothelial carcinoma (UCC): Document if requested as single‑agent therapy, prior progression during/after platinum‑containing chemotherapy, and presence of locally advanced or metastatic disease

Muscle invasive bladder cancer (MIBC): Confirm planned neoadjuvant use with gemcitabine + cisplatin and whether durvalumab will be given as adjuvant single‑agent therapy following radical cystectomy

Prior Authorization Submission and Provider Requirements

Prior Authorization

Prior Authorization Submission and Response Time

Prior Authorization Required: Submit a completed prior authorization (PA) form. Fax completed form to: (855) 840-1678. Save time — submit online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. Our standard response time for prescription drug coverage requests is 5 business days. If the request is urgent, call (800) 882-4462 to expedite.

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
SureScripts via EHR
Standard response time: 5 business days
Urgent requests: call (800) 882-4462

Documentation Required

Provider Must Supply Completed Patient and Prescriber Information

Provider must supply a fully completed PA form with all asterisked (*) items. Required patient and prescriber information includes physician name, specialty, DEA/NPI/TIN, office contact, patient name, Cigna ID, date of birth, patient and office addresses, and phone/fax. Medication specifics (requested drug, dose, quantity, duration, frequency, ICD-10) and clinical details (weight, diagnosis, biomarker information where applicable) must be included. Incomplete forms will prevent fax response due to privacy regulations.

Complete all asterisked (*) fields on the form
Include DEA, NPI or TIN for prescriber
Provide Cigna ID and patient DOB
Specify medication, dose, quantity, duration, frequency, ICD-10
Provide patient weight and relevant clinical/diagnostic details

Denial Risk

Infusion Site and Site-of-Care Re-direction

Infusion site rules: Per some Cigna plans, infusion MUST occur in the lowest-cost medically appropriate setting. If infusion is occurring in a hospital outpatient setting, indicate this on the form. The plan may require re-direction to a lower-cost alternate setting (e.g., ambulatory infusion site, physician office, or home) with assistance of a Specialty Care Option Case Manager when medically appropriate. Provide medical necessity rationale if hospital outpatient administration is requested and the patient is not a candidate for redirection.

Note if infusion is in hospital outpatient facility
If yes, indicate whether patient is candidate for re-direction to AIS, MDO, or home and provide rationale if not
Indicate whether patient is candidate for home infusion or if physician has in-office infusion site
Failure to use lowest-cost medically appropriate setting may affect coverage

Key Definitions and Biomarker Criteria

dMMR / MSI-H — biomarker options captured on the form for indication-specific eligibility

Form biomarker optionsForm captures dMMR and MSI-H status as selectable options for relevant indications (Endometrial, Esophageal/EGJ, Gastric)

Endometrial-specific biomarker questionForm asks whether the patient’s disease is mismatch repair deficient (dMMR) (Yes/No)

Esophageal/EGJ biomarker choicesForm lists: Deficient mismatch repair (dMMR), Microsatellite instability-high (MSI-H), Others

Gastric carcinoma biomarker choicesForm lists: Deficient mismatch repair (dMMR), Microsatellite instability-high (MSI-H), Others

Combination regimen linkageForm pairs biomarker questions with intent to use durvalumab +/- tremelimumab or with cytotoxic combinations where applicable

Resectable disease (NSCLC) — surgical and tumor characteristics captured for neoadjuvant/adjuvant eligibility

Resectability questionForm asks whether NSCLC is resectable or unresectable (Resectable disease / Unresectable disease)

Tumor size / node positivityForm specifically defines resectable as tumors at least 4 cm and/or node positive (Yes/No)

Locally advanced / unresectable statusForm asks if the patient has locally advanced, unresectable disease (Yes/No)

Post-chemoradiotherapy progressionForm asks whether disease progressed following chemoradiotherapy (Yes/No)

Molecular status capturedForm asks EGFR-positive and ALK rearrangement-positive status (Yes/No) to inform neoadjuvant/adjuvant eligibility

Platinum-containing neoadjuvant intentForm asks if durvalumab will be given with platinum-containing chemotherapy as neoadjuvant treatment followed by single-agent adjuvant durvalumab after surgery (Yes/No)

Initial Prescribing Information and Required Regimen Details

Initial prescribing information

Form captures initial regimen details and dosing presentation choices.

Dose selection: Select vial presentation (Imfinzi 120 mg/2.4 mL vial OR Imfinzi 500 mg/10 mL vial) and specify prescribed dose, dose frequency, quantity, duration of therapy, ICD‑10 diagnosis code, and patient weight as provided on the form

Vial selection determines dispensing presentation; include ICD‑10 and current weight per form

Site-of-Care and Step-Therapy Considerations

Step/Setting rule	Form question / action
If infusion is occurring in a facility affiliated with a hospital outpatient setting, some Cigna plans require that infusion occur in the lowest cost, medically appropriate setting; the plan may require redirection to an alternate setting (e.g., ambulatory infusion suite, medical office, home) with assistance from a Specialty Care Option Case Manager.
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Step/Setting rule

Form question / action

If infusion is occurring in a facility affiliated with a hospital outpatient setting, some Cigna plans require that infusion occur in the lowest cost, medically appropriate setting; the plan may require redirection to an alternate setting (e.g., ambulatory infusion suite, medical office, home) with assistance from a Specialty Care Option Case Manager.

{"text":"Form asks: 'Is this infusion occurring in a facility affiliated with hospital outpatient setting?' (Yes / No). If Yes, form asks: 'Is this patient a candidate for re-direction to an alternate setting (such as AIS, MDO, home) with assistance of a Specialty Care Option Case Manager?' and prompts for medical necessity rationale if not a candidate. The form also asks whether the patient is a candidate for home infusion and whether the physician has an in-office infusion site (Yes / No responses).','status':""}

Where Medication Will Be Obtained / Dispensed

Note

Select site of care — home, office, infusion center, or hospital outpatient

Indicate the intended site of medication acquisition/administration on the form; Accredo Specialty Pharmacy is listed as Cigna's nationally preferred specialty pharmacy and the form captures options for home, office, infusion center, or hospital outpatient.

Site options on the form: Accredo Specialty Pharmacy; Prescriber's office stock (medical claim); Retail pharmacy; Home Health / Home Infusion vendor; Other (specify).
Accredo contact methods and identifiers are provided (e-prescribe, fax, verbal) for placing orders.
Form asks whether infusion is occurring in a hospital outpatient affiliated facility and whether the patient is a candidate for home infusion or in-office infusion.