Cigna Health Assessment Form – Fill Out and Use This PDF

The Cigna Health Assessment form is a critical document used to request prior authorization for the medication Humira (adalimumab), an essential treatment for conditions such as rheumatoid arthritis and Crohn's disease. By thoroughly completing this form, including specific patient information and medical history, healthcare providers can help ensure a timely review process by Cigna HealthCare. Prompt and accurate filling out of this form is vital to avoid delays or adverse determinations due to insufficient information.

To assist your patients in receiving their necessary medications without delay, make sure to fill out the Cigna Health Assessment form by clicking the button below.

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Cigna Health Assessment Form PDF Details

In today's healthcare landscape, navigating the specifics of medication coverage can be a daunting task for both healthcare providers and patients. Among the various forms and procedures, the Cigna Health Assessment form for Humira (adalimumab) stands out due to its comprehensive approach towards prior authorization. This form serves a critical bridge in ensuring patients receive the necessary medication by meticulously detailing requirements ranging from provider and patient information, medication specifics, to detailed medical history and current treatment regimens. Designed to streamline the decision-making process for drug coverage, it prompts the provider to document the patient's medical condition, prior treatments, and the rationale behind choosing Humira. Additionally, stipulations around secure faxing procedures reflect a keen sensitivity to privacy concerns, ensuring compliance with regulations and safeguarding patient information. The form also facilitates consideration of a patient's response to Humira, making it a vital tool for continued therapy assessments. As part of Cigna's pharmacy services, this prior authorization form embodies the intricate balance between regulatory requirements, clinical judgement, and patient care—ultimately influencing the timely access to essential medications for conditions like Anklyosing Spondylitis, Psoriatic Arthritis, Crohn’s Disease, and more.

Question	Answer
Form Name	Cigna Health Assessment Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cigna humira pa form, cigna health risk assessment form, cigna prior authorization form, cigna humira form

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Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Humira (adalimumab) -

Notice: Failure to complete this form in its entirety or include chart notes 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:

Humira (adalimumab) 40mg/.8ml kit

Humira (adalimumab) 40mg/.8ml pen kit

Dose and Quantity:

Duration of therapy:

J-Code:

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):

Please indicate the condition Humira is being used to treat and answer additional questions as necessary. You may include applicable chart notes with this form.

Anklyosing Spondylitis

Additional Question(s)

	Does patient have a history of beneficial clinical			Answer/Detail:
	Does patient have a history of beneficial clinical			Answer/Detail:
	response to Humira (adalimumab)?


	Does patient have evidence of failure, intolerance or			Answer/Detail:
	contraindication to Non-Steroidal Anti-Inflammatory
	(NSAID) medications?

Psoriatic Arthritis

Additional Question(s)

	Does patient have a history of beneficial clinical	Answer/Detail:
	response to Humira (adalimumab)?

	Does patient have evidence of failure, intolerance or	Answer/Detail:
	Does patient have evidence of failure, intolerance or	Answer/Detail:
	contraindication to Methotrexate therapy?

Active Crohn’s Disease

Additional Question(s)

Does patient have a history of beneficial clinical response to Humira (adalimumab)?

Answer/Detail:

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

Does patient have evidence of failure, intolerance or contraindication, or inadequate response to conventional therapies (such as aminosalicylate, corticosteroids or immumodulators)?

Answer/Detail:

Rheumatoid Arthritis or Juvenile Idiopathic Arthritis

What is the patient’s diagnosis?		Rheumatoid Arthritis	Juvenile Idiopathic Arthritis

What is the patient’s current weight?

Does the patient have a history of beneficial clinical response to Humira 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):

Which of the following methods was used to measure the patient’s disease progression PRIOR to therapy on Humira? (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 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 Humira on any of the following measurements? (Check all that showed a beneficial response to Humira 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

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score Other (please specify) :

Additional pertinent information:

Chronic Plaque Psoriasis

Does patient have a history of beneficial clinical response to Humira (adalimumab)?

Yes

Is the patient a candidate for, or have they previously received, systemic therapy (Methotrexate, cyclosporin,

soriatane)?

Yes

Is the patient a candidate for, or have they previously received, phototherapy (Narrow and Broad Band UVB, PUVA)?

Yes

Other (Please specify diagnosis and any additional applicable 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. Phone requests may be submitted by calling (800)244-6224.

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 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.

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CIGNA HealthCare Prior Authorization Form – Humira – Page 2 of 2

Cigna Health Assessment Form – Fill Out and Use This PDF

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