Cigna Orthovisc Form PDF Details

Orthovisc is one of the many medications that is used to assist with the relief of pain and inflammation in people who suffer from osteoarthritis. If you are considering using Orthovisc to treat your osteoarthritis, it is important that you understand how the medication works and what to expect from its use. In this blog post, we will provide an overview of Orthovisc and explain how to get a prescription for the medication. We will also discuss some of the potential side effects associated with Orthovisc treatment. Finally, we will provide advice on how to best manage your orthoarthritis symptoms using this medication. Thanks for reading!

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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