Cigna Prior Auth Form PDF Details

Navigating the healthcare system can often feel overwhelming, especially when it comes to understanding the necessary steps to ensure medication coverage. The Cigna Prior Authorization Form plays a pivotal role in this process, serving as a crucial bridge between physicians, patients, and the insurance provider to confirm coverage for specific medications before they are prescribed. This form requires detailed information from the healthcare provider about the patient, including their personal details, medication requested, and medical diagnosis, ensuring a thorough review by Cigna. It distinguishes between urgent and standard requests, emphasizing the importance of timely care, especially in situations where delaying treatment could seriously jeopardize a patient’s health. Additionally, this document delves into prior treatments, including generic alternatives and their outcomes, to assess the necessity of the requested medication. The form also highlights the ease of the online submission process through platforms like CoverMyMeds and SureScripts, aiming to streamline the prior authorization process. With a standard review time of five business days for prescription drug coverage requests, Cigna encourages urgent cases to be expedited through direct communication. This form embodies Cigna's commitment, represented by its Tree of Life logo, to enabling access to necessary medications, ensuring policyholders receive the care they require promptly and efficiently.

QuestionAnswer
Form NameCigna Prior Auth Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna botox prior authorization form, cigna botox pa form, cigna botox form, cigna prior authorization form for botox

Form Preview Example

Fax completed form to: (855) 840-1678

If this is an URGENT request, please call (800) 882-4462 (800.88.CIGNA)

Medication Prior

Authorization Form

 

 

PHYSICIAN INFORMATION

 

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Physician Name:

 

 

 

 

 

*Due to privacy regulations we will not be able to respond via fax

 

 

 

 

 

 

 

 

 

with the outcome of our review unless all asterisked (*) items on

 

 

 

Specialty:

 

* DEA or TIN:

 

 

 

 

 

 

 

 

this form are completed.*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Contact Person:

 

 

 

 

 

* Patient Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Phone:

 

 

 

 

 

* Cigna ID:

 

 

* Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Fax:

 

 

 

 

 

* Patient Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Street Address:

 

 

 

 

 

City:

 

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip:

 

Patient Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Urgency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Standard

 

Urgent (In checking this box, I attest to the fact that applying the standard review time frame may

 

 

 

 

 

 

seriously jeopardize the customer’s life, health, or ability to regain maximum function)

 

 

 

 

 

 

 

 

 

 

 

Medication requested: (please specify name, strength, and dosing schedule)

 

 

 

 

 

 

 

Duration of therapy:

 

 

 

 

 

Quantity:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis related to use:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[For pain medications only]: Does the patient have a terminal illness?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternative Medications:

 

 

 

 

 

 

 

 

 

 

 

Has your patient ever received the generic alternative of the requested medication?

 

 

 

 

 

 

 

 

Yes

No

No generic available

 

 

 

 

 

 

 

 

(if yes) Did your patient try more than one manufacturer of this generic?

Yes

 

No

Unavailable

 

Please provide the following details for each trial: manufacturer name, date(s) taken and for how long, and what the documented results were of taking the drug, including any intolerances or adverse reactions your patient experienced.

(please note that the manufacturer's information can be obtained through the dispensing pharmacy):

Drug Name

Dates taken & how long

Documented results, including intolerances/adverse

reactions the patient experienced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your patient ever received any other alternative treatments for this diagnosis?

Yes

No

(if yes) Please provide the following details: date(s) taken and for how long, and what the documented results were of taking

this drug, including any intolerances or adverse reactions your patient experienced:

 

 

Drug Name

Dates taken & how long

Documented results, including intolerances/adverse

reactions the patient experienced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(if no to any question above) Is your patient able to use any other alternatives for this diagnosis?

Yes

No

(if no) Please provide the reason(s) why your patient is unable to use the available alternative(s):

Additional pertinent information: (please include other clinical reasons for drug, relevant lab values, etc.)

Save Time! Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, it is important that

you call us to expedite the request. View our Prescription Drug List and Coverage Policies online at cigna.com.

v091619

“Cigna" is a registered service mark, and the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include, for example, Cigna Health and Life Insurance Company and Cigna Health Management, Inc. Address: Cigna Pharmacy Services, PO Box 42005,

Phoenix AZ 85080-2005

How to Edit Cigna Prior Auth Form Online for Free

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cigna prior authorization form botox spaces to fill in

Within the box Alternative Medications Has your, Yes, No generic available, if yes Did your patient try more, Yes, Unavailable, Please provide the following, Drug Name, Dates taken how long, Documented results including, Has your patient ever received any, Yes, if yes Please provide the, Drug Name, and Dates taken how long type in the data the application requests you to do.

step 2 to finishing cigna prior authorization form botox

The application will require for further details in order to easily fill in the section if no to any question above Is, and Yes.

stage 3 to completing cigna prior authorization form botox

Identify the rights and responsibilities of the parties within the space Save Time Submit Online at, Our standard response time for, and Cigna is a registered service mark.

cigna prior authorization form botox Save Time Submit Online at, Our standard response time for, and Cigna is a registered service mark fields to complete

Step 3: Select the Done button to be sure that your completed form is available to be transferred to each gadget you decide on or sent to an email you indicate.

Step 4: Create at least several copies of your document to keep away from any possible future challenges.

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