Cigna Health Assessment Form – Fill Out and Use This PDF

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

Psoriatic Arthritis

Active Crohn’s Disease

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

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

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 HealthCare Prior Authorization Form – Humira – Page 2 of 2