As you may be aware, Cigna requires pre-approval for Rituxan therapy. This can often lead to frustration on the part of both physicians and patients alike, as obtaining this approval can seem like a daunting task. In this blog post, we will outline the process for obtaining pre-approval from Cigna for Rituxan therapy and provide some tips to make it a little less cumbersome. We hope you find this information helpful!
Question | Answer |
---|---|
Form Name | Cigna Rituxan Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | cigna rituxan prior auth form, cigna prior auth rituxan, cigna prior authorization form 2019, cigna rituxan auth form |
|
|
CIGNA HealthCare Prior Authorization Form |
|
|
- Rituxan (rituximab) - |
Pharmacy Services |
|
|
Phone: |
Notice: Failure to complete this form in its entirety may result in delayed |
|
Fax: |
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: |
||
|
|
|
|
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): |
|
|
|
|
|
|
|
Diagnosis related to use (please specify): |
|
|
|
Rheumatoid Arthritis |
|
|
|
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
|
|||
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 |
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
Elevation of ESR (> 28 mm/hr), or
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 |
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 |
|
At least a 20% improvement according to ACR 20% response criteria |
ESR or |
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
Our standard response time for prescription drug coverage requests is
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.,
CIGNA HealthCare Prior Authorization Form – Rituxan – Page 2 of 2