Medication Prior Authorization Form - Complete and Fax or Call

Sep 17, 2026

Medication Prior Authorization Form for collecting physician and patient details to support review of a requested medication. The form gathers prescribing provider information, patient demographics, urgency selection, medication and diagnosis information, duration of therapy, and related ICD10 codes. It also requests documentation of prior generic alternatives and other treatments, including manufacturer, dates, outcomes, intolerances, or adverse reactions. Include attestation, prescriber signature, and fax submission contacts for urgent versus standard review timelines.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Physician information

Patient information

Urgency

Medication requested and diagnosis

Alternative medications and prior trials

Additional pertinent information

Attestation and signature

Fax completed form to: (855) 840-1678 If this is an URGENT request, please call (800) 882-4462 (800.88.CIGNA) Medication Prior Authorization Form | PHYSICIAN INFORMATION | | | | | PATIENT INFORMATION | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | * Physician Name: | | | | *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. * | | | | | | Specialty: | | * DEA, NPI or TIN: | | | | | | | | Office Contact Person: | | | | * Patient Name: | | | | | | Office Phone: | | | | * Cigna ID: | | | * Date of Birth: | | | Office Fax: | | | | * Patient Street Address: | | | | | | Office Street Address: | | | | City: | | State: | | Zip: | | City: | State: | | Zip: | Patient Phone: | | | | | | Urgency:
Standard Urgent (In checking this box, I attest to the fact that applying the standard review time frame may
seriously jeopardize the customer’s life, health, or ability to regain maximum function) | | | | | | | | | | Medication requested: (please specify name, strength, and dosing schedule)
Duration of therapy: Quantity: ICD10: | | | | | | | | | | Is the requested medication for a chronic or long-term condition for which the prescription medication may be necessary for the life of
the patient? Yes No | | | | | | | | | | Diagnosis related to use: | | | | | | | | | | Alternative Medications:
Has your patient ever received the generic alternative of the requested medication?
Yes No No generic available
(if yes) Did your patient try more than one manufacturer of this generic? Yes No Unavailable
Please provide the following details for each trial: manufacturer name, date(s) taken and for how long, and what the documented results were of taking the drug, including any intolerances or adverse reactions your patient experienced.
(please note that the manufacturer's information can be obtained through the dispensing pharmacy):
Drug Name Dates taken & how long Documented results, including intolerances/adverse reactions the patient experienced
Has your patient ever received any other alternative treatments for this diagnosis? Yes No
(if yes) Please provide the following details: date(s) taken and for how long, and what the documented results were of taking
Drug Name Dates taken & how long Documented results, including intolerances/adverse reactions the patient experienced
this drug, including any intolerances or adverse reactions your patient experienced: | | | | | | | | | | (if no to any question above) Is your patient able to use any other alternatives for this diagnosis? Yes No
(if no) Please provide the reason(s) why your patient is unable to use the available alternative(s): | | --- | | Additional pertinent information: (please include other clinical reasons for drug, relevant lab values, etc.) | | Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan or insurer its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the
information reported on this form.
Prescriber Signature: Date: | | Save Time! [Submit Online at:](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts)[ ](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts)[www.covermymeds.com/main/prior-authorization-forms/cigna/](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts)[ or via SureScripts](Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts) in your EHR. | | Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, it is important that you cal

FAQs

Where should the completed prior authorization form be sent, and what is the urgent contact?

Fax the completed form to (855) 840-1678. For urgent requests, call (800) 882-4462.

What patient and physician details are required on the form?

The form requires physician name, specialty, DEA/NPI/TIN, office contact person and phone/fax, and patient name, Cigna ID, date of birth, street address, and phone. Asterisked (*) items must be completed to receive faxed review outcomes.

What information is needed about alternative medications and prior trials?

Indicate whether the patient received generic alternatives and whether multiple manufacturers were tried. Provide manufacturer name, date(s) taken and duration, and documented results, including intolerances or adverse reactions; similarly document other alternative treatments if applicable.

Sep 17, 2026

Upload by Aria Callaghan