Cigna Prior Authorization Form Botox Details

If you are a Cigna customer and need to have a prescription filled, you may be required to obtain prior authorization from Cigna. This form must be completed by your doctor and submitted to Cigna before your prescription can be filled. The requirements for prior authorization vary depending on the medication you need. This blog post will provide an overview of the Cigna prior auth form, including what it is used for and how to complete it. We'll also provide some tips for getting your prescription filled quickly and easily.

In the table, there's some information concerning the cigna prior auth form. This page will give you specifics of the form's size, finalization time, and the blanks you are expected to fill.

QuestionAnswer
Form NameCigna Prior Auth Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescigna botox prior authorization form pdf, cigna botox auth form, cigna prior authorization forms, cigna botox form

Form Preview Example

Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Botox (botulinum toxin type A) -

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 asterisked (*)

 

Specialty:

 

* DEA or TIN:

 

 

 

 

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:

Botox 100 unit vial

 

 

 

Dose and Quantity:

Duration of therapy:

J-Code:

CPT Code:

In what location(s) of the body will Botox injections be given (please specify how many units are being injected into each muscle and how often they will be given)?

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 Botox is being used to treat and answer additional questions as necessary. Please include all applicable chart notes with this form.

Blepharospasm

Cervical dystonia, including spasmodic torticollis

 

 

 

 

Additional

 

 

Is the patient’s condition causing persistent pain or interfering

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question(s)

 

 

with the patient's ability to perform age-related activities of

 

 

 

 

 

 

 

 

 

 

 

 

daily living?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Focal hand dystonia (e.g., writer's cramp)

 

 

Additional

Is the patient’s condition causing persistent pain or interfering

Answer/Detail:

 

 

Question(s)

with the patient's ability to perform age-related activities of

 

 

 

 

 

daily living?

 

 

 

 

 

 

 

 

 

 

Adductor spasmodic dysphonia/laryngeal dystonia

 

 

 

 

 

 

 

 

 

 

Jaw-closing oromandibular dystonia

 

 

 

 

 

 

 

 

 

Additional

Is the patient’s condition causing persistent pain, interference

Answer/Detail:

 

 

Question(s)

with nutritional intake (e.g., masticatory dysfunction that

 

 

 

 

 

results in weight loss or malnutrition), or significant speech

 

 

 

 

 

impairment/interference with the ability to communicate

 

 

 

 

 

effectively?

 

 

 

 

 

 

 

 

Meige's syndrome/cranial dystonia (i.e., blepharospasm with jaw-closing oromandibular cervical dystonia)

CIGNA HealthCare Prior Authorization Form – Botox – Page 1 of 3

Additional Question(s)

Is the patient’s condition causing persistent pain, interference with nutritional intake (e.g., masticatory dysfunction that results in weight loss or malnutrition), or significant speech impairment/interference with the ability to communicate effectively?

Answer/Detail:

Spasticity due to cerebral palsy (including spastic equinus foot deformities)

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Spasticity due to cerebrovascular accident

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Spasticity due to localized adductor muscle spasticity in multiple sclerosis

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Spasticity due to spinal cord injury

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Spasticity due to traumatic brain injury

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Spasticity due to hereditary spastic paraplegia

Additional Question(s)

What is the specific location of the spasticity?

Answer/Detail:

Hemifacial spasms/Seventh cranial nerve palsy

Additional Question(s)

Is the patient’s condition causing persistent pain or vision impairment?

Answer/Detail:

Horizontal strabismus in an adult

Additional Question(s)

 

How many prism diopters does the patient have?

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient have diplopia, impaired depth perception,

 

 

Answer/Detail:

 

 

 

impaired peripheral vision, or impaired ability to maintain

 

 

 

 

 

 

fusion?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vertical strabismus in an adult

 

Additional

Does the patient have diplopia, impaired depth perception,

Answer/Detail:

 

 

Question(s)

impaired peripheral vision, or impaired ability to maintain

 

 

 

fusion?

 

 

 

 

 

 

 

 

 

Persistent sixth nerve palsy in an adult

 

 

 

 

Additional

 

 

When was the patient diagnosed with this condition?

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient have diplopia, impaired depth perception,

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

 

impaired peripheral vision, or impaired ability to maintain

 

 

 

 

 

 

 

 

 

 

 

 

fusion?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Strabismus disorder in a child

 

Additional

Is Botox being used to achieve normal binocular motor

Answer/Detail:

 

Question(s)

alignment?

 

 

 

 

 

 

 

 

 

 

 

 

Primary esophogeal achalasia

 

 

Additional

 

 

Is the patient considered a poor surgical risk (e.g., patients

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

 

 

 

 

Question(s)

 

 

with comorbidities such as elderly patients with decreased life

 

 

 

 

 

 

 

 

 

 

expectancy)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CIGNA HealthCare Prior Authorization Form – Botox – Page 2 of 3

Does the patient have a history of perforation caused by previous pneumatic dilatation?

Answer/Detail:

Chronic anal fissure

Additional Question(s)

Has the patient failed conventional non-surgical treatment (e.g., nitrate preparations, sitz baths, stool softeners, bulk agents, diet modifications)

Answer/Detail:

Primary or secondary axillary or palmar hyperhidrosis OR gustatory sweating (Frey's syndrome)

Additional Question(s)

 

Has patient had prior trial of topical therapy? If yes please list

 

 

Answer/Detail:

 

 

 

agent, duration and outcome.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has patient had prior trial of oral pharmacotherapy? If yes

 

 

Answer/Detail:

 

 

 

please list drug, duration and outcome.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the condition significantly interfering with the patient's ability

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

to perform age-appropriate activities of daily living?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The condition is causing persistent or chronic cutaneous

 

 

Answer/Detail:

 

 

 

conditions such as skin maceration, dermatitis, fungal

 

 

 

 

 

 

infections and secondary microbial conditions?

 

 

 

 

 

 

 

 

 

 

 

 

Disabling essential tremor, including head and neck, hand, and voice tremor

Excessive glandular secretion

Additional Question(s)

 

Does the patient have cholinergic-mediated secretions associated

 

 

Answer/Detail:

 

 

 

 

 

 

 

 

with various types of fistulas (e.g., parotid gland,

 

 

 

 

 

 

pharyngocutaneous)?

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient have ptyalism/sialorrhea (excessive salivation)

 

 

Answer/Detail:

 

 

 

associated with parkinsonism and cerebral palsy, refractory to

 

 

 

 

 

 

pharmacotherapy (including anticholinergics)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voiding dysfunction associated with intracranial lesions or cerebrovascular accident-induced voiding difficulty

Voiding dysfunction associated with detrusor sphincter dyssynergia due to spinal cord injury

Migraine Prophylaxis

Additional Question(s)

Did the patient have a failure, contraindication, or intolerance to two migraine prophylaxis medications: beta-blockers, calcium channel blockers, tricyclic antidepressants or anticonvulsant medications?

Answer/Detail:

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. Due to the clinical information required, requests for Botox cannot be accepted via phone.

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 have the request expedited. View our formulary on line at http://www.cigna.com.

v041310

“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.

CIGNA HealthCare Prior Authorization Form – Botox – Page 3 of 3