Cigna Rituxan Form PDF Details

Navigating the process of securing coverage for necessary medications can often be a challenging endeavor for healthcare providers. The CIGNA HealthCare Prior Authorization Form for Rituxan (rituximab) serves as a critical tool in this journey, designed to streamline the process of obtaining prior approval for this medication from the insurance provider. A detailed completion of this form is paramount, as any missing information could lead to delays or denials, directly impacting patient care. This form requires comprehensive provider and patient information, including specific diagnoses and previous treatments, underscoring the necessity of a thorough understanding of the patient's medical history and the proposed plan of care. It delves into the diagnosis-related use of Rituxan, from rheumatoid arthritis to various forms of lymphoma and leukemia, asking for detailed past treatment responses and the specific need for Rituxan. Additionally, the form addresses the logistics of medication delivery, from preferred pharmacies to direct delivery options, ensuring that every aspect of the patient’s treatment pathway is meticulously planned and accounted for. This meticulous approach helps ensure that patients receive the best possible care by facilitating access to essential medications in a timely manner.

QuestionAnswer
Form NameCigna Rituxan Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna rituxan prior auth form, cigna prior auth rituxan, cigna prior authorization form 2019, cigna rituxan auth form

Form Preview Example

 

 

CIGNA HealthCare Prior Authorization Form

 

 

- Rituxan (rituximab) -

Pharmacy Services

 

Phone:

(800)244-6224

Notice: Failure to complete this form in its entirety may result in delayed

Fax:

(800)390-9745

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:

Rituxan (rituximab) 10mg/ml vial

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

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

 

Home Health / Home Infusion vendor

Other (please specify):

 

 

 

 

 

 

Diagnosis related to use (please specify):

 

 

Rheumatoid Arthritis

Non-Hodgkin’s Lymphoma

 

 

relapsed/refractory Waldenstrom's macroglobulinemia

immune or idiopathic thrombocytopenic purpura

Relapsed/refractory chronic lymphocytic leukemia

Other (please specify):

 

 

 

 

Rheumatoid Arthritis:

 

 

 

Does the patient have a history of positive clinical response to Rituxan therapy?

 

Yes

No

 

 

Please indicate if the patient has had evidence of failure, inadequate response, intolerance or contraindication to any of the following

disease-modifying anti-rheumatic drugs (DMARDs). Please check all that apply:

 

Methotrexate

Azathioprine

Gold

Hydroxychloroquine

Penacillamine

Sulfasalazine

Other (please specify):

Which of the following methods was used to measure the patient’s disease progression PRIOR to therapy on Rituxan? (Check all that apply):

Health Assessment Questionnaire Disease Index (HAQ-DI)

Visual Analogue scale (VAS)

Likert scales of global response to pain by the patient/doctor

Global Arthritis Score (GAS)

Clinical Disease Activity Index (CDAI)

Simplified Disease Activity Index (SDAI)

Progression of radiographic damage of involved joints

Disease Activity Scale (DAS) score

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

Elevation of ESR (> 28 mm/hr), or C-reactive protein (CRP) (2x the upper limit of normal)

Other (please specify) :

(Continued on page 2)

CIGNA HealthCare Prior Authorization Form – Rituxan – Page 1 of 2

Rheumatoid Arthritis (continued):

Has the patient had inadequate response, intolerance or contraindication to any of following Tumor Necrosis Factor (TNF) Antagonists?

Humira (adalimumab)

Enbrel (etanercept)

Remicade (infliximab)

If this is a request for CONTINUED THERAPY (after at least 16 weeks of treatment), has the patient shown positive response to treatment with Kineret based on any of the following measurements? (Check all that showed a positive response to Kineret therapy):

Health Assessment Questionnaire Disease Index (HAQ-DI)

Visual Analogue scale (VAS)

Likert scales of global response to pain by the patient/doctor

Global Arthritis Score (GAS)

Clinical Disease Activity Index (CDAI)

Simplified Disease Activity Index (SDAI)

Progression of radiographic damage of involved joints

Disease Activity Scale (DAS) score

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

At least a 20% improvement according to ACR 20% response criteria

ESR or C-reactive protein (CRP)

Other (please specify) :

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.

V041610

“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 – Rituxan – Page 2 of 2

Cigna Rituxan Form isn’t the one you’re looking for?

Related Documents