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.

QuestionAnswer
Form NameCigna Health Assessment Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna humira pa form, cigna health risk assessment form, cigna prior authorization form, cigna humira form

Form Preview Example

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

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:

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

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:

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

No

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

soriatane)?

Yes

No

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

Yes

No

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