866 873 8279-2026

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The document is a Medication Prior Authorization Form from CIGNA HealthCare, outlining the necessary information required from healthcare providers to process medication requests. It emphasizes the importance of completing all sections to avoid delays or adverse determinations and provides contact information for submitting the form via fax or phone. Additionally, it mentions the standard response time for requests and includes links to view coverage positions and formulary alternatives.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Provider Information' section. Enter your name, specialty, DEA or TIN, office contact person, and office phone number.
Next, complete the 'Patient Information' section. Input the patient's name, CIGNA ID, date of birth, street address, city, state, zip code, and phone number.
In the 'Medication Requested' field, specify the medication name, strength, and dosing schedule. Ensure you provide accurate details for a smooth review process.
Fill in the diagnosis related to the medication use and duration of therapy. This information is crucial for determining coverage.
List any formulary alternatives that have been tried along with their trial lengths or if samples were provided.
Finally, include any additional pertinent information such as clinical reasons for drug use and relevant lab values.

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