CurrentCignaPolicy N/A

Imjudo (tremelimumab-actl) prior authorization form — coverage criteria and site-of-care guidance

Prior authorization and site-of-care information for Imjudo (tremelimumab-actl) injectable solutions for Cigna members; intended for prescribers and infusion providers submitting requests for coverage and administration.

Policy Summary

PayerCigna

PolicyImjudo (tremelimumab-actl) prior authorization form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form (including all asterisked items, medication directions, J-code, weight, ICD-10, and disease-specific details) via fax or CoverMyMeds/SureScripts to initiate review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2presentations

5 business daysstandard review

1preferred specialty pharmacy

6indication checkboxes

Coverage Criteria

General PA requirements

Coverage consideration guided by completion of indication-specific clinical items

Form completion and clinical data: All required patient/prescriber fields (asterisked items), medication details (dose, quantity, duration, J-code), and disease-specific clinical responses (see form checkboxes) must be provided to support prior authorization review.

Form collects items for HCC, NSCLC, esophageal/esophagogastric junction cancer, gastric cancer including combination use with Imfinzi and tumor biomarkers (EGFR/ALK/MSI-H/dMMR).

Coding and Patient Identifiers

Billing code placeholdermixed

J-code

J-code (to be specified on form)

Patient weight (dosing)

FieldPatient's current weight

Policy Summary

PayerCigna

PolicyImjudo (tremelimumab-actl) prior authorization form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

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.

Required on form for dosing calculations

Location on formListed under 'Directions for use' section alongside Quantity, Duration, J-code, ICD10

Entry formatProvider-entered numeric weight (as specified on form)

Provider Actions & Submission Requirements

Prior Authorization

Prior authorization submission & review timeframe

Submit prior authorization requests using the completed form. Fax the completed form to (855) 840-1678 or 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 (800.88.CIGNA) to expedite.

Fax: (855) 840-1678
Online: CoverMyMeds portal or SureScripts in EHR
Standard review time: 5 business days
Urgent requests: call (800) 882-4462

Documentation Required

Site‑of‑care consideration

Per some Cigna plans, infusion must occur in the least intensive, medically appropriate setting. Indicate the planned site of administration on the form (Patient's Home, Physician's Office, Hospital Outpatient, Other) and confirm whether the physician has an in‑office infusion site.

Document site of care on the form (home, office, hospital outpatient, other)
Confirm if physician has an in‑office infusion site

Documentation Required

Required documentation on form

Complete all required patient and prescriber fields on the form. We will not be able to respond via fax with the outcome of our review unless all items marked with * are completed. Provide all clinical information and attestations (including disease stage, prior therapy, performance status, relevant biomarkers/mutations, planned combination agents and dosing, weight, ICD‑10, J‑code, quantity, and duration). Prescriber must sign and date the attestation.

Complete all asterisked (*) patient and prescriber fields
Include clinical details: disease stage, prior therapies, performance status, biomarkers (EGFR/ALK/MSI‑H/dMMR when applicable)
Provide medication directions: quantity, duration, J‑code, patient weight
Prescriber signature and date required

Denial Risk

Incomplete form / non‑urgent handling

If necessary clinical information, required asterisked items, or the prescriber attestation/signature are missing, the request may be delayed or not processed. Incomplete, non‑urgent requests will be handled in standard business timelines (5 business days); urgent requests lacking required information should be clarified by phone to avoid denial or delay.

Incomplete forms may prevent a response via fax
Non‑urgent incomplete requests processed within standard timelines (5 business days)
Call for urgent issues to expedite if information is missing

Background

Imjudo (tremelimumab-actl) is an injectable immune checkpoint inhibitor indicated for use in multiple solid tumor types and may be used in combination with durvalumab (Imfinzi) for certain indications. The prior authorization form collects indication-specific clinical items (for example, unresectable HCC, metastatic NSCLC, EGFR/ALK status, MSI-H/dMMR for esophageal or gastric cancers) to support a medical necessity determination and documents whether Imjudo will be given with Imfinzi when applicable.

Definitions

Imjudo — tremelimumab-actl

Drug nameImjudo (tremelimumab-actl)

FormulationSolution for injection (presentations listed elsewhere on form)

Clinical contextUsed for multiple solid tumor types; form collects indication-specific clinical items (HCC, NSCLC, esophageal/esophagogastric, gastric)

Combination therapyForm asks if medication will be used in combination with Imfinzi (durvalumab)

DocumentationPrescriber attestation and signature required on form

Initial Therapy Criteria

Order details

Medication presentation and ordering details

Product selection: Provider must specify Imjudo presentation (25mg/1.25ml or 300mg/15ml), directions, quantity, duration, and J-code on the form.

Patient's current weight and ICD-10 diagnosis must be completed on the form for dosing and billing.

Step Therapy

Step	Requirement
1	Site-of-care may be constrained by plan to the least intensive, medically appropriate setting; provider must indicate intended administration site (Patient's Home, Physician's Office, Hospital Outpatient, or Other) on the form.

Site of Care Details

Note

Document administration site and procurement

Indicate the intended administration setting on the form (home, physician office, hospital outpatient, or other) and document procurement method; the form captures site and acquisition details to support plan site-of-care requirements.

Select where the drug will be administered: Patient's Home, Physician's Office, Hospital Outpatient, or Other
Select where medication will be obtained (Accredo, hospital outpatient, retail, home infusion, physician office stock) and supply pharmacy contact as applicable