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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 phone details.
- Next, complete the 'Patient Information' section. Ensure you provide all asterisked (*) items such as patient name, CIGNA ID, date of birth, and address.
- In the 'Medication Requested' field, select the appropriate Enbrel dosage and specify the duration of therapy along with any relevant J-Code.
- Indicate where the medication will be obtained by selecting from options like retail pharmacy or CIGNA Tel-Drug.
- For diagnosis related to use, check all applicable conditions such as Rheumatoid Arthritis or Psoriatic Arthritis.
- Finally, review all sections for completeness before submitting via fax at (800)390-9745. Ensure that all required fields are filled to avoid delays.
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Related links
For authorization, please answer each question and fax this form PLUS chart notes back to the Health Choice Utah. Prior Authorization Department at 385-425-4052Read more
The list of services that require prior authorization is available in narrative form, along with a more detailed list by CPT and HCPCS codes. Molina priorRead more
The Child/Adolescent Inpatient Extension PA Request Form can be submitted up to two (2) business days prior to the last day of the current authorization. BasedRead more