Get Proton Pump Inhibitor (chronic Use) Coverage Request Form - Cigna

This guide provides clear, step-by-step instructions on how to complete the Proton Pump Inhibitor (Chronic Use) Coverage Request Form for Cigna online. Ensuring that you fill out the form completely is crucial for timely processing.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the provider information, including the provider name, specialty, DEA or TIN, office contact person, and office phone and fax numbers.
3. Input the patient information. Include the patient's name, Cigna ID, date of birth, phone number, and their street address, city, state, and zip code.
4. Answer the security questions regarding your fax machine's location and whether responses can be faxed to your office.
5. Select the medication requested from the list of proton pump inhibitors, noting that Cigna has preferred agents like Omeprazole 20mg, Prevacid, and .
6. Provide the strength and dose, and check all relevant diagnoses related to the medication request.
7. If GERD is selected, specify if the patient has failed treatment with listed agents at the required doses for at least 30 days.
8. If an ulcer diagnosis is indicated, confirm that the patient tested negative for H. pylori and provide the testing date, or confirm positive results and treatment details.
9. For erosive esophagitis, indicate the grade of the condition and whether a stricture is present.
10. List any formulary alternatives that have been tried by the patient.
11. Once the form is fully completed, ensure to save your changes. You can download, print, or share the form as necessary.

Complete your coverage request form online today for prompt processing.