Cigna Orthovisc Form PDF Details

Navigating the healthcare system can sometimes feel like an intricate dance, especially when it involves obtaining authorization for necessary medications. For patients dealing with painful osteoarthritis of the knee, getting coverage for relief can be critical. The Cigna Orthovisc form is a vital piece of this puzzle for those insured by CIGNA HealthCare. This prior authorization form, specifically catering to medications like Synvisc, Hyalgan, Supartz, and Orthovisc, serves as a request to determine if the insurer will cover the medication. It requires detailed information, ranging from provider and patient specifics to clinical data supporting the need for the medication. The form emphasizes the importance of completing all sections thoroughly to avoid delays or denials due to insufficient information. Additionally, it outlines the options for where the medication can be obtained and asks for a comprehensive list of prior medications and any conservative therapies already tried. The process underscores CIGNA HealthCare's effort to manage prescription drug coverage effectively, with resources available online for providers to understand coverage positions and submit these crucial forms properly. With the potential for faxed communications depending on the security of the machine and completion of all necessary fields, it ensures a streamlined approach to managing patient care, provided all instructions are meticulously followed.

QuestionAnswer
Form NameCigna Orthovisc Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescigna orthovisc prior authorization form, authorization supartz, cigna synvisc form, authorization synvisc

Form Preview Example

Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Synvisc, Hyalgan, Supartz, Orthovisc -

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

Synvisc

Hyalgan

 

Supartz

Orthovisc

Other (please specify):

 

 

 

 

 

 

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

 

 

 

 

 

 

 

Home Health / Home Infusion vendor

 

 

 

Prescriber’s office stock (billing on a medical claim form)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (please specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical Data:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis related to use (please specify):

 

 

 

 

 

 

 

 

 

 

 

Does this patient have painful osteoarthritis of the knee?

 

 

Yes

 

No

 

Which prior analgesic medications (including acetaminophen, NSAIDs and COX-II Inhibitors) has the patient tried? Please provide the medication name, dose, dates of use, and please note any adverse effects of medications:

Does this patient have a contraindication to analgesics (such as acetaminophen, NSAIDs or COX-II Inhibitors)?

Yes

No

If YES, please specify the contraindication:

Please note any conservative non-pharmacologic therapies tried (for example, physical therapy, etc.):

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. 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

V 042710

 

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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