Cigna tel drug specialty pharmacy form 2026

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The document is a fax order form for CIGNA Specialty Pharmacy Services specifically designed for high-risk maternity patients. It includes sections for patient and physician information, prescription details for medications such as Makena and Zofran, and requirements for home health services. The form also requests clinical information to justify the prescribed medications and outlines the process for submitting orders.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, health care ID number, and contact details. Ensure all phone numbers are provided for scheduling delivery.
Next, complete the 'Physician Information' section. Include the physician's name, NPI, DEA number, and address. This information is crucial for processing prescriptions.
In the 'Prescription Information' section, specify medications required. For each medication like MAKENA® or Zofran, indicate directions for use and quantity/refills needed.
If applicable, provide clinical information regarding Zofran or Makena usage. This includes diagnosis and previous therapies attempted.
Finally, ensure that the physician signs and dates the form to confirm accuracy before submission.

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