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.
Question | Answer |
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Form Name | Cigna Prior Auth Form |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | cigna botox prior authorization form pdf, cigna botox auth form, cigna prior authorization forms, cigna botox form |
Pharmacy Services
Phone:
Fax:
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
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* Provider Name: |
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**Due to privacy regulations we will not be able to respond via |
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fax with the outcome of our review unless all asterisked (*) |
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Specialty: |
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* DEA or TIN: |
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items on this form are completed** |
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Office Contact Person: |
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* Patient Name: |
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Office Phone: |
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* CIGNA ID: |
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Office Fax: |
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* Date Of Birth: |
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* Is your fax machine kept in a secure location? |
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* May we fax our response to your office? |
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Office Street Address: |
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Patient Phone: |
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Medication requested:
Botox 100 unit vial |
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Dose and Quantity: |
Duration of therapy: |
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
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
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Additional |
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Is the patient’s condition causing persistent pain or interfering |
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Answer/Detail: |
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Question(s) |
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with the patient's ability to perform |
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daily living? |
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Focal hand dystonia (e.g., writer's cramp)
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Additional |
Is the patient’s condition causing persistent pain or interfering |
Answer/Detail: |
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Question(s) |
with the patient's ability to perform |
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daily living? |
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Adductor spasmodic dysphonia/laryngeal dystonia |
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Additional |
Is the patient’s condition causing persistent pain, interference |
Answer/Detail: |
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Question(s) |
with nutritional intake (e.g., masticatory dysfunction that |
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results in weight loss or malnutrition), or significant speech |
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impairment/interference with the ability to communicate |
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effectively? |
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Meige's syndrome/cranial dystonia (i.e., blepharospasm with
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)
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How many prism diopters does the patient have? |
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Answer/Detail: |
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Does the patient have diplopia, impaired depth perception, |
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Answer/Detail: |
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impaired peripheral vision, or impaired ability to maintain |
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fusion? |
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Vertical strabismus in an adult
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Additional |
Does the patient have diplopia, impaired depth perception, |
Answer/Detail: |
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Question(s) |
impaired peripheral vision, or impaired ability to maintain |
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fusion? |
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Persistent sixth nerve palsy in an adult
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Additional |
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When was the patient diagnosed with this condition? |
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Answer/Detail: |
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Question(s) |
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Does the patient have diplopia, impaired depth perception, |
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Answer/Detail: |
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impaired peripheral vision, or impaired ability to maintain |
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fusion? |
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Strabismus disorder in a child
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Additional |
Is Botox being used to achieve normal binocular motor |
Answer/Detail: |
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Question(s) |
alignment? |
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Primary esophogeal achalasia
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Is the patient considered a poor surgical risk (e.g., patients |
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Answer/Detail: |
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Question(s) |
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with comorbidities such as elderly patients with decreased life |
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expectancy)? |
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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
Answer/Detail:
Primary or secondary axillary or palmar hyperhidrosis OR gustatory sweating (Frey's syndrome)
Additional Question(s)
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Has patient had prior trial of topical therapy? If yes please list |
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Answer/Detail: |
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agent, duration and outcome. |
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Has patient had prior trial of oral pharmacotherapy? If yes |
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Answer/Detail: |
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please list drug, duration and outcome. |
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Is the condition significantly interfering with the patient's ability |
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Answer/Detail: |
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to perform |
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The condition is causing persistent or chronic cutaneous |
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Answer/Detail: |
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conditions such as skin maceration, dermatitis, fungal |
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infections and secondary microbial conditions? |
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Disabling essential tremor, including head and neck, hand, and voice tremor
Excessive glandular secretion
Additional Question(s)
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Does the patient have |
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Answer/Detail: |
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with various types of fistulas (e.g., parotid gland, |
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pharyngocutaneous)? |
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Does the patient have ptyalism/sialorrhea (excessive salivation) |
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Answer/Detail: |
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associated with parkinsonism and cerebral palsy, refractory to |
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pharmacotherapy (including anticholinergics)? |
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Voiding dysfunction associated with intracranial lesions or cerebrovascular
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:
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
Our standard response time for prescription drug coverage requests is
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.,
CIGNA HealthCare Prior Authorization Form – Botox – Page 3 of 3