Cigna Tel Drug Fax Form PDF Details

The Cigna Tel-Drug Prescription Order Form is a crucial tool for individuals seeking to manage their prescription needs effectively. It serves as a representation of accuracy by the individual submitting it, ensuring the information provided is correct and complete. This form requires users to print information clearly using black or blue ink and to meticulously fill out Steps 1 through 4, and, if necessary, Steps 5 and/or 6, to avoid delays in processing. To maintain the integrity of the prescription process, it is essential to include the original prescription(s) and payment method; copies of prescriptions are not accepted, and items must not be stapled to the form. The form encompasses sections for insurance cardholder information including temporary shipping addresses, choice of shipping method with options ranging from standard to special shipping at variable costs, and detailed payment instructions, including an option for direct billing to credit cards for applicable copayments, coinsurance, deductibles, and special shipping costs. Furthermore, it provides space to declare any allergies or major health conditions, thereby customizing patient care. The option to request generic substitutions for brand-name medications unless indicated otherwise by the patient or prescriber highlights the form's adherence to pharmacy laws and potential cost savings for the patient. The Cigna Tel-Drug form is not only a medium for ordering initial prescriptions but also offers a seamless method to handle refills, emphasizing convenience with options to order by phone or online, showcasing the comprehensive and user-centric approach of the Cigna Tel-Drug service.

QuestionAnswer
Form NameCigna Tel Drug Fax Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCardholders, cigna home delivery fax number for physicians, Pennsylvania, cigna home delivery fax form for physicians

Form Preview Example

CIGNA Tel-Drug Prescription Order Form

 

By submitting this form you are representing that the information provided is correct.

 

.

 

 

. Please print all information clearly with black or blue ink.

 

.

Please complete Steps 1, 2, 3 and 4. Then complete Step 5 and/or 6 as needed.

 

Incomplete information may delay processing.

 

.

Please enclose payment method and original prescription(s) only. Copies of prescription(s) will not be accepted.

505

Please do not staple any items to this form.

STEP 1: INSURANCE CARDHOLDER INFORMATION

Cardholder ID #

 

 

 

Cardholder’s

 

 

 

 

 

 

TEMPORARY SHIPPING ADDRESS

 

(SEE INSURANCE CARD)

Full Name

 

 

 

 

 

 

 

 

 

(FOR THIS ORDER ONLY)

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

In Care of Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

 

Zip Code (+ 4)

Temp Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home (

)

 

 

Alternate

(

)

 

 

 

 

 

Temp City

 

 

Temp

 

Phone

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder’s

 

 

 

Cardholder’s

 

 

 

 

 

 

Temp Zip Code

 

Temp Phone

 

Employer

 

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: SHIPPING

 

 

 

 

 

 

 

 

 

STEP 3: PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If this section is left blank, Standard Shipping will be used.

Refrigerated shipments will be expedited at no additional cost.

Check ( ) the box for the Shipping Method of your choice. You are responsible for the cost of SPECIAL SHIPPING.

Shipping Method

# of Days

Cost

Standard Shipping

Standard Delivery

$0.00

USPS PRIORITY MAIL

2-3 Days

$5.25

USPS EXPRESS MAIL

Overnight

$17.95

FEDERAL EXPRESS

Overnight

$17.95

Failure to include complete payment information may delay or prevent shipment of order.

Check ( ) the box for the Payment method of your choice.

Enclosed is a check or money order made payable to CIGNA Tel-Drug.

I authorize CIGNA Tel-Drug to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsurance and/or deductible(s), payments due for any medications not covered under my benefit plan, plus any special shipping costs.

Complete credit card information is required for each order.

Check ( ) credit card type and enter corresponding credit card information below.

UPS OVERNIGHT

Overnight (by 12:00 noon)

$17.95

UPS SAVER

Overnight (by 7 pm)

$16.95

SPECIAL SHIPPING expedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject to change by carrier without prior notification and may vary depending on weight and zone.

American Express

Discover

MasterCard

VISA

Credit

Card #

Expiration

/

Date (MM/YY)

 

 

Name on

 

Credit Card

 

I would like to pay full price for the medication(s) listed below. Do not bill my insurance.

Medication Name and Strength

Medication Name and Strength

584001 Rev. 05/2006

Don’t forget to complete the remaining steps on the reverse side.

STEP 4: ALLERGIES & HEALTH CONDITIONS

Please complete this section every time a medication is ordered.

Patient’s Full Name

Male /

Birth Date

Include nickname, Jr./Sr., etc.

Female

 

 

 

 

 

/

/

 

 

/

/

 

 

/

/

 

 

/

/

 

 

 

 

None

Aspirin

Cephalosporins

Codeine

Erythromycin

Ibuprofen

Penicillin

Sulfa

If no allergies are checked (

), for new customers this

indicates no known allergies

and for existing customers

this indicates no change.

 

 

 

 

Other Allergies

 

Major Health Conditions

 

 

 

 

STEP 5: REFILL PRESCRIPTIONS

For your convenience, you can order refills by calling our automated system at 1.800.TEL.DRUG (835.3784) option 1 or by visiting us at mycigna.com . Do not include refills on this form that you plan to order by phone or Internet. Refills from other pharmacies should not be included on this form.

Patient’s Full Name

Birth Date

CIGNA Tel-Drug Rx Number

Medication Name and Strength

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

STEP 6: NEW PRESCRIPTIONS

PHARMACY LAW PERMITS PHARMACISTS TO SUBSTITUTE A LESS EXPENSIVE GENERICALLY EQUIVALENT MEDICATION FOR A BRAND NAME

MEDICATION UNLESS YOU OR YOUR PRESCRIBER INDICATE OTHERWISE. BY CHECKING (

) "BRAND ONLY", YOU MAY INCUR A HIGHER COST.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ( ) ONE

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Full Name

Birth Date

Fill

Do Not

Medication Name & Strength

 

( ) if

Prescriber’s/Physician’s

Prescriber’s/Physician’s

Now

Fill

 

Brand

Full Name

 

Phone Number

 

 

 

Now*

 

 

Only

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* By checking this option, you are indicating you do not want the prescription filled at this time. Please contact CIGNA Tel-Drug when the medication is needed.

Thank you for choosing CIGNA Tel-Drug.

You can call us at 1.800.TEL.DRUG (835.3784) or visit us at www.teldrug.com.

You can also write to us or mail this order form to CIGNA Tel-Drug, PO Box 1019, Horsham PA 19044.

At times it may be necessary to switch manufacturers on generic medications. This may cause a change in appearance (size, shape and/or color) of the medication.584001 (BACK) Rev. 05/2006 CIGNA Tel-Drug refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation.

How to Edit Cigna Tel Drug Fax Form Online for Free

Filling in documents with this PDF editor is simpler compared to most things. To enhance Rx the document, there is nothing you need to do - only stick to the steps down below:

Step 1: To start out, click the orange button "Get Form Now".

Step 2: Now you can alter the Rx. This multifunctional toolbar will allow you to include, eliminate, modify, and highlight content material or perhaps conduct several other commands.

These sections will make up the PDF document:

portion of gaps in cigna home delivery fax number for physicians

The software will expect you to fill out the Standard Shipping, Standard Delivery, USPS PRIORITY MAIL, Days, USPS EXPRESS MAIL, Overnight, FEDERAL EXPRESS, Overnight, UPS OVERNIGHT, Overnight by noon, UPS SAVER, Overnight by pm, SPECIAL SHIPPING expedites carrier, I authorize CIGNA TelDrug to bill, and American Express part.

Filling out cigna home delivery fax number for physicians part 2

Type in the required details while you're on the Patients Full Name Include, Male Female, Birth Date, s n i r o p s o a h p e C, t y r E, e n e d o C, n i r i p s A, e n o N, o r p u b, c n e P, u S, Other Allergies, Major Health Conditions, For your convenience you can order, and Patients Full Name area.

Completing cigna home delivery fax number for physicians stage 3

The Patients Full Name, Birth Date, Fill Now, Do Not Fill Now, Medication Name Strength, Check if Brand Only, PrescribersPhysicians Full Name, PrescribersPhysicians Phone Number, By checking this option you are, At times it may be necessary to, and BACK Rev segment enables you to identify the rights and obligations of all sides.

cigna home delivery fax number for physicians Patients Full Name, Birth Date, Fill Now, Do Not Fill Now, Medication Name  Strength, Check   if Brand Only, PrescribersPhysicians Full Name, PrescribersPhysicians Phone Number, By checking this option you are, At times it may be necessary to, and BACK Rev blanks to complete

Step 3: Click the Done button to be certain that your finalized form is available to be transferred to any electronic device you decide on or sent to an email you specify.

Step 4: To prevent any kind of complications down the road, you should create at the very least two or three copies of the form.

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