Cigna And Remicade – Fill Out and Use This PDF

The Cigna HealthCare Prior Authorization Form for Remicade (infliximab) is a necessary document for healthcare providers to request approval from Cigna for prescribing Remicade, a medication used in the treatment of various autoimmune diseases. It contains sections for provider and patient information, medication dosage and frequency, diagnosis, and details of previous treatments and responses. To ensure a smooth and timely review process, it's crucial for providers to complete all required sections of the form accurately. Click the button below to start filling out the form today.

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Cigna And Remicade PDF Details

In the realm of healthcare, where precision and timely decisions are crucial, the Cigna HealthCare Prior Authorization Form for Remicade (infliximab) plays a significant role in the treatment process for various chronic conditions. This document is essential for healthcare providers seeking authorization for their patients to receive Remicade, a medication that has proven effective against a range of illnesses such as Rheumatoid Arthritis, Psoriatic Arthritis, and others including Crohn's disease and Ulcerative Colitis. The form requires detailed input on provider and patient information, ensuring proper communication and privacy adherence, highlighted by the necessity to fill all sections marked with an asterisk to facilitate a response from Cigna. Moreover, it outlines specific criteria regarding the patient's medical history, previous responses to Remicade, and prior treatments to justify the necessity for this medication, emphasizing the importance of an accurate and comprehensive completion to avoid delays or adverse decisions. Cigna also provides avenues for obtaining the medication, whether through its Tel-Drug service or other sources, ensuring flexibility and accessibility for the patient. Additionally, the form serves as a gateway to understanding Cigna's stance on Remicade within their coverage framework, with a prompt to view their medication coverage positions online. This form, while a common administrative task, is a critical step in ensuring patients receive the necessary treatment promptly and efficiently, underlying the interconnectedness of healthcare providers, insurance entities, and pharmacy services in managing chronic conditions.

Question	Answer
Form Name	Cigna And Remicade
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cigna remicade prior authorization form, cigna prior auth, cigna auth forms remicade, cigna infliximab prior auth form

Form Preview Example

Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Remicade (infliximab) -

Notice: Failure to complete this form in its entirety may result in delayed

processing or an adverse determination for insufficient information.

PROVIDER INFORMATION

PATIENT INFORMATION

* Provider Name:

**Due to privacy regulations we will not be able to

respond via fax with the outcome of our review unless all

Specialty:

* DEA or TIN:

asterisked (*) items on this form are completed**

Office Contact Person:

* Patient Name:

Office Phone:

* CIGNA ID:

Office Fax:

* Date Of Birth:

* Is your fax machine kept in a secure location?

Yes

* Patient Street Address:

* May we fax our response to your office?

Yes

Office Street Address:

City

State

Zip

City

State

Zip

Patient Phone:

Medication requested:

Remicade (infliximab) 100mg vial		Other (please specify):
Dose and Quantity:	Duration of therapy:			J-Code:
Frequency of administration:

Where will this medication be obtained?
CIGNA Tel-Drug (CIGNA's nationally preferred specialty pharmacy)*			Retail pharmacy
Prescriber’s office stock (billing on a medical claim form)			Home Health / Home Infusion vendor
Other (please specify):
*If you wish to order this medication from CIGNA Tel-Drug, please call 1-800-351-3606 for an order form.

Diagnosis related to use (please specify):
Rheumatoid Arthritis		Psoriatic Arthritis		Active Ankylosing Spondylitis
Chronic Plaque Psoriasis		Ulcerative Colitis		Crohn’s disease
Fistulizing Crohn’s disease		Inflammatory Bowel Disease Arthritis		Other (please specify):
What is the patient’s current weight?
Has this patient been on Remicade in the past?		Yes	No
If YES, what was the previous dosage?
Does the patient have history of beneficial clinical response to Remicade (infliximab) therapy?					Yes	No

Psoriatic or Reactive Arthritis:
Does patient have evidence of failure, intolerance or contraindication to Methotrexate therapy?					Yes	No

Rheumatoid Arthritis:
Will this medication be used in combination with Methotrexate therapy?			Yes		No

Please indicate if the patient has had evidence of failure, inadequate response, intolerance or contraindication to any of the following

disease-modifying anti-rheumatic drugs (DMARDs). Please check all that apply:
Methotrexate	Azathioprine	Gold	Hydroxychloroquine
Penacillamine	Sulfasalazine	Other (please specify):

(Continued on page 2)

CIGNA HealthCare Prior Authorization Form – Remicade – Page 1 of 2

If YES, please specify which medications:

Which of the following methods was used to measure the patient’s disease progression PRIOR to therapy on Remicade? (Check all that apply):

Health Assessment Questionnaire Disease Index (HAQ-DI)	Visual Analogue scale (VAS)
Likert scales of global response to pain by the patient/doctor	Global Arthritis Score (GAS)
Clinical Disease Activity Index (CDAI)	Simplified Disease Activity Index (SDAI)
Progression of radiographic damage of involved joints	Disease Activity Scale (DAS) score

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

Elevation of ESR (> 28 mm/hr), or C-reactive protein (CRP) (2x the upper limit of normal)

Other (please specify) :

If this is a request for CONTINUED THERAPY (after at least 16 weeks of treatment), has the patient shown beneficial response to treatment with Remicade based on any of the following measurements? (Check all that showed a beneficial response to Remicade therapy):

Health Assessment Questionnaire Disease Index (HAQ-DI)	Visual Analogue scale (VAS)
Likert scales of global response to pain by the patient/doctor	Global Arthritis Score (GAS)
Clinical Disease Activity Index (CDAI)	Simplified Disease Activity Index (SDAI)
Disease Activity Scale (DAS) score	ESR or C-reactive protein (CRP)

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

At least a 20% improvement according to ACR 20% response criteria

Other (please specify) :

Chronic Plaque Psoriasis:

Does the patient have history of beneficial clinical response to Remicade (infliximab) therapy?

Is the patient a candidate for systemic therapy?

Is the severity great enough that the patient is a candidate for Photo Therapy?

Is this a request for a renewal of a previously granted authorization?

If YES, please document improvement since beginning therapy:

Yes

Crohn’s Disease:

Has the patient had failure, contraindication, or intolerance to conventional therapies such as aminosalicylate, corticosteroids, or immunomodulators?

Yes No

Did the patient have a failure or intolerance to adalimumab (Humira) therapy?

Yes

Fistulizing Crohn’s Disease:

How long have fistulas persisted?

Inflammatory Bowel Disease Arthritis:

Has the patient had failure, contraindication, or intolerance to sulfasalazine, azathioprine, steroids, or, methotrexate?

Yes

Ankylosing Spondylitis:

Has the patient had failure, contraindication, or intolerance to non-steroidal anti-inflammatory drugs (NSAIDs)?

Yes

Ulcerative colitis:

Has the patient had failure, contraindication, or intolerance to conventional therapies such as corticosteroids (e.g, prednisone, methylprednisolone), 5-aminosalicylic acid agents (e.g., sulfasalazine, mesalamine, balsalazide), or immunosuppressants (e.g., azathioprine, cyclosporine, 6-mercaptopurine)?

Yes

If YES, please specify which medications:

Additional pertinent information:

CIGNA HealthCare’s coverage position on this and other medications may be viewed online at:

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions

Please fax completed form to (800)390-9745.

Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent, it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http://www.cigna.com.

“CIGNA Pharmacy Management” or “CIGNA HealthCare” refer to various operating subsidiaries of CIGNA Corporation. Products and services	V 041610

are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-
Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.

CIGNA HealthCare Prior Authorization Form - Remicade - Page 2 of 2

How to Edit Cigna And Remicade Online for Free

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Step 1: Click the button "Get Form Here".

Step 2: The file editing page is now open. Include text or enhance current details.

Enter the details requested by the software to create the form.

portion of blanks in cigna remicade prior authorization form

Fill in the Rheumatoid Arthritis Chronic, Psoriatic Arthritis Ulcerative, Active Ankylosing Spondylitis, What is the patients current weight, Has this patient been on Remicade, Yes, If YES what was the previous dosage, Does the patient have history of, Yes, Psoriatic or Reactive Arthritis, Yes, Rheumatoid Arthritis Will this, Yes, Please indicate if the patient has, and Methotrexate Penacillamine space with the information asked by the platform.

stage 2 to finishing cigna remicade prior authorization form

The system will require information to automatically fill up the segment Which of the following methods was, Health Assessment Questionnaire, Visual Analogue scale VAS Global, If this is a request for CONTINUED, Health Assessment Questionnaire, Visual Analogue scale VAS Global, Chronic Plaque Psoriasis Does the, Is the patient a candidate for, Is the severity great enough that, Is this a request for a renewal of, If YES please document improvement, Yes, Yes, Yes, and Yes.

part 3 to finishing cigna remicade prior authorization form

The Crohns Disease Has the patient had, Yes, If YES please specify which, Did the patient have a failure or, Yes, Fistulizing Crohns Disease How, Inflammatory Bowel Disease, Yes, Ankylosing Spondylitis Has the, Yes, Ulcerative colitis Has the patient, Yes, If YES please specify which, and Additional pertinent information section is going to be place to insert the rights and responsibilities of both sides.

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Step 3: As soon as you select the Done button, your finished document can be simply transferred to each of your gadgets or to email specified by you.

Step 4: Be sure to create as many copies of your file as possible to avoid potential problems.

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