Loading
Form preview picture

Get Cigna medication prior authorization form 2010

CIGNA HealthCare - Medication Prior Authorization Form Pharmacy Services Notice Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information. Phone 800 244-6224 Fax 800 390-9745 PROVIDER INFORMATION PATIENT INFORMATION Provider Name Specialty Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked items on this form are completed DEA or TIN Office Contact Person Patient Name Office Phone CIGNA ID Office Fax Date Of Birth Is your fax machine kept in a secure location May we fax our response to your office Yes Office Street Address City No Patient Street Address State Zip Patient Phone Medication requested please specify name strength and dosing schedule Diagnosis related to use Duration of therapy Formulary alternatives tried please include length of trial and/or if samples were given Additional pertinent information please include clinical reasons for drug relevant lab values etc. http //www. cigna*com/customercare/healthcareprofessional/coveragepositions Please fax completed form to 800 390-9745. Phone requests may be submitted by calling 800 244-6224. Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http //www. cigna*com* V 041510 CIGNA Pharmacy Management or CIGNA HealthCare refer to various operating subsidiaries of CIGNA Corporation* Products and services are provided by these subsidiaries and not by CIGNA Corporation* These subsidiaries include Connecticut General Life Insurance Company Tel-Drug Inc* Tel-Drug of Pennsylvania L*L*C. cigna*com/customercare/healthcareprofessional/coveragepositions Please fax completed form to 800 390-9745. Phone requests may be submitted by calling 800 244-6224. Our standard response time for prescription drug coverage requests is 2-4 business days. Phone requests may be submitted by calling 800 244-6224. Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http //www. If your request is urgent it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http //www. cigna*com* V 041510 CIGNA Pharmacy Management or CIGNA HealthCare refer to various operating subsidiaries of CIGNA Corporation* Products and services are provided by these subsidiaries and not by CIGNA Corporation* These subsidiaries include Connecticut General Life Insurance Company Tel-Drug Inc* Tel-Drug of Pennsylvania L*L*C. cigna*com/customercare/healthcareprofessional/coveragepositions Please fax completed form to 800 390-9745. Phone requests may be submitted by calling 800 244-6224. Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http //www. .

How It Works

entirety rating
4.9Satisfied
362 votes

How to fill out and sign healthcare online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

The preparing of lawful documents can be high-priced and time-consuming. However, with our predesigned web templates, everything gets simpler. Now, using a Cigna medication prior authorization form takes at most 5 minutes. Our state browser-based samples and complete guidelines eradicate human-prone faults.

Adhere to our easy steps to get your Cigna medication prior authorization form well prepared quickly:

  1. Select the web sample in the library.
  2. Type all necessary information in the required fillable fields. The easy-to-use drag&drop interface allows you to add or move fields.
  3. Check if everything is completed appropriately, without typos or missing blocks.
  4. Apply your e-signature to the page.
  5. Click on Done to save the adjustments.
  6. Download the data file or print out your copy.
  7. Distribute instantly to the receiver.

Take advantage of the quick search and innovative cloud editor to produce a precise Cigna medication prior authorization form. Remove the routine and make documents on the internet!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing TEL

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Cigna medication prior authorization form

  • SUBSIDIARIES
  • Dosing
  • entirety
  • healthcare
  • TEL
  • expedite
  • ADVERSE
  • specify
  • viewed
  • insufficient
  • pertinent
  • provider
  • duration
  • alternatives
  • DEA
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.