Cigna Prior Auth Form – Fill Out and Use This PDF

Updated: Oct 29, 2026

The Cigna Prior Authorization Form is a crucial document designed to ensure that certain medications or medical services are covered under a patient’s health plan before they are accessed. It requires detailed information regarding the physician, patient, and the requested medication or treatment, highlighting the necessity of comprehensive documentation for the approval process. To expedite your healthcare service delivery, consider filling out the form by clicking the button below.

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Cigna Prior Auth Form PDF Details

The Cigna Prior Authorization Form is required before Cigna approves coverage for certain prescription drugs, specialty medications, or medical services. Physicians submit the form on behalf of their patients to confirm medical necessity before treatment begins.

The form collects information across several key areas. The prescriber section requires the physician's name, NPI number, fax number, and office phone number. The patient section requires the Cigna member ID, date of birth, and primary diagnosis code. The treatment section specifies the medication or procedure requested, including dosage, strength, quantity, and clinical indication.

Cigna distinguishes between standard and urgent prior authorization requests. Urgent requests apply when delaying treatment could seriously jeopardize the patient's health. Standard prescription drug coverage requests are reviewed within five business days. Medical benefit requests may follow a different timeline.

Electronic submission is available through CoverMyMeds and SureScripts, which connect directly with pharmacy and hospital systems. Fax submission is also accepted using the fax number printed on the form. Cigna processes each request by reviewing the submitted clinical information against its coverage guidelines before issuing a determination.

Question	Answer
Form Name	Cigna Prior Auth Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	cigna botox prior authorization form, cigna botox pa form, cigna botox form, cigna prior authorization form for botox

How to Fill Out Medication Prior Authorization Form

Medication Prior Authorization Form at a glance

What it is: This is the Medication Prior Authorization Form.

Where and when to file: Fax the completed form to (855) 840-1678.

A filled-in Medication Prior Authorization Form example: a standard request after a generic

Medication Prior Authorization Form example filled out, example: a standard request after a generic — Dr. Sample's office asks Cigna to approve a medication for a patient. The request is standard, and the patient tried one manufacturer's generic without relief. The picture shows page 1, and its names and figures are sample values. The Standard box is checked, so the Urgent box stays empty. The medication is not for pain, so the terminal illness boxes stay empty. Only one generic trial is entered, so the other two generic trial rows stay empty. The patient took no other alternative treatments, so nothing goes in the other alternative treatments rows because there were none. The patient is not able to use another alternative, and the reasons go on page 2, which the picture does not show. The fillable form has no field for the medication requested, duration of therapy or quantity, so the example leaves them blank and you enter them on the printed form by hand.

How to fill out Medication Prior Authorization Form, box by box

Physician information and patient information

Enter the PHYSICIAN INFORMATION and the PATIENT INFORMATION: Physician Name, Specialty, DEA or TIN, Office Contact Person, Office Phone, Office Fax, Office Street Address, City, State and Zip, then Patient Name, Cigna ID, Date of Birth, Patient Street Address, City, State and Zip, and Patient Phone. Due to privacy regulations Cigna will not be able to respond via fax with the outcome of the review unless all asterisked (*) items on this form are completed.

Urgency

Urgency: check Standard or Urgent. In checking the Urgent box, you 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.

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

If your request is urgent, it is important that you call to expedite the request.

Pain medications only: terminal illness

For pain medications only: does the patient have a terminal illness? Check Yes or No.

Alternative medications: the generic alternative

Alternative Medications: has your patient ever received the generic alternative of the requested medication? Check Yes, No or No generic available. If yes, did your patient try more than one manufacturer of this generic? Check Yes, No or 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.

Write the Drug Name, the Dates taken & how long, and the Documented results, including intolerances/adverse reactions the patient experienced.

Other alternative treatments for this diagnosis

Has your patient ever received any other alternative treatments for this diagnosis? Check Yes or No. If yes, write the Drug Name, the Dates taken & how long, and the Documented results, including intolerances/adverse reactions the patient experienced.

Is your patient able to use any other alternatives

If no to any question on alternatives: is your patient able to use any other alternatives for this diagnosis? Check Yes or No.

If no, please provide the reason(s) why your patient is unable to use the available alternative(s). Under Additional pertinent information, please include other clinical reasons for drug, relevant lab values, etc.

Common questions about Medication Prior Authorization Form

How long does a pre-authorization usually take?

The standard response time for prescription drug coverage requests is 5 business days.

Where do I file it?

Fax the completed form to (855) 840-1678. Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Sources

[1] Medication Prior Authorization Form, Cigna (the Official source link on this page).