Get Cigna Uniform Pharmacy Prior Authorization Request Form 2020-2025

Filling out the Cigna Uniform Pharmacy Prior Authorization Request Form online is essential for ensuring that necessary prescription medications are covered. This guide provides a step-by-step overview to assist users in accurately completing the form.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. Begin filling out the form by providing the patient information, including the patient's name, date of birth, address, phone number, and email address.
3. Next, provide the prescribing provider information. Include the prescriber's name, fax number, phone number, NPI, DEA, and tax ID.
4. Indicate whether the requested drug is intended to treat opioid dependence, and respond to whether this is a first request within a 12-month period.
5. Select the type of prior authorization request: new request or reauthorization, and include relevant patient diagnosis and ICD diagnostic code(s).
6. List the drug(s) requested along with their strength, route, frequency, unit/volume, start date, and length of therapy.
7. Specify the location of treatment, including provider name, address, and tax ID if applicable.
8. Include clinical criteria for approval and any other pertinent information, such as other medications tried and patient responses.
9. If applicable, provide details for clinical trials, including the trial name and registration number.
10. Complete the prescription section, indicating the drug's brand name, strength, dose, quantity, and number of refills.
11. Select the delivery location for the drug: to the patient’s home or to the physician's office.
12. Finally, ensure the prescriber's or authorized signature is included along with the date and the dispensing pharmacy's name and phone number.
13. Once all sections are completed, save your changes, and you can download, print, or share the form as needed.

Complete the Cigna Uniform Pharmacy Prior Authorization Request Form online to streamline the medication approval process.