Ciagna Remicade Prior Authorization Details

Cigna and Remicade are the most recent of a series of pharmaceutical companies to announce that they will no longer cover usage of biologics, such as Humira and Remicade. These drugs have been shown to be highly effective for treating autoimmune diseases like lupus or rheumatoid arthritis, yet their high cost has caused many insurance providers to stop covering them. Cigna is among the latest company to stop coverage for these drugs after previously announcing in 2018 that it would not cover treatments for new customers starting on January 1st, 2020. This announcement comes after Cigna's $52 billion purchase by pharmacy giant Express Scripts in March 2019.

Here is some data that may be handy if you are seeking to learn just how long it will take you to fill out cigna and remicade and just how many PDF pages it contains.

QuestionAnswer
Form NameCigna And Remicade
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna infliximab prior auth form, cigna prior authorization form for remicade, cigna authorization form remicade, cigna prior auth

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

No

* Patient Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

* May we fax our response to your office?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Yes

Yes

Yes

No

No

No

No

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

No

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

No

Ankylosing Spondylitis:

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

Yes

No

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

No

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