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. .