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The form collects physician information and patient details, including required fields marked with asterisks to enable a review outcome response. It captures urgency (standard vs urgent attestation), medication name, strength, dosing, therapy duration and quantity, and diagnosis linked to use. 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Yes  No |  |  |  |  |  |  |  |\n| Alternative Medications:\u003Cbr>Has your patient ever received the generic alternative of the requested medication?\u003Cbr> Yes  No  No generic available\u003Cbr>(if yes) Did your patient try more than one manufacturer of this generic?  Yes  No  Unavailable\u003Cbr>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.\u003Cbr>(please note that the manufacturer's information can be obtained through the dispensing pharmacy):\u003Cbr>Drug Name Dates taken & how long Documented results, including intolerances/adverse reactions the patient experienced\u003Cbr>Has your patient ever received any other alternative treatments for this diagnosis?  Yes  No\u003Cbr>(if yes) Please provide the following details: date(s) taken and for how long, and what the documented results were of taking this drug, including any intolerances or adverse reactions your patient experienced:\u003Cbr>Drug Name Dates taken & how long Documented results, including intolerances/adverse reactions the patient experienced\u003Cbr>(if no to any question above) Is your patient able to use any other alternatives for this diagnosis?  Yes  No |  |  |  |  |  |  |  |\n\n\n| (if no) Please provide the reason(s) why your patient is unable to use the available alternative(s): |\n| --- |\n| Additional pertinent information: (please include other clinical reasons for drug, relevant lab values, etc.) |\n| 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. |\n| Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, it is important that you call us to expedite [the request. View our Prescription Drug List and Coverage Policies online at cigna.com](the request. View our Prescription Drug List and Coverage Policies online at cigna.com). |\n\nv091619  \n“Cigna\" is a registered service mark, and the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidi","cbCaiuE0NQboqmzx","https://ap.wps.com/l/cbCaiuE0NQboqmzx","pdf",61828,"English","# Physician Information\n## Patient Information\n# Medication Request Details\n## Alternatives and Clinical Information\n# Submission and Response Time","[{\"question\":\"Where should the completed form be sent, and what if the request is urgent?\",\"answer\":\"Fax the completed form to (855) 840-1678. If it is urgent, call (800) 882-4462 to expedite the request.\"},{\"question\":\"Which items are required to receive the review outcome by fax?\",\"answer\":\"Asterisked (*) items must be completed. Due to privacy regulations, the review outcome cannot be sent via fax unless all asterisked items are completed.\"},{\"question\":\"What information is required about alternative medications or treatments?\",\"answer\":\"Provide whether the patient received generic alternatives or other alternative treatments, including details such as manufacturer names, dates taken and duration, and documented results including intolerances or adverse reactions. If alternatives cannot be used, provide the reasons.\"}]","Medication Prior Authorization Form - Submit Online | PDF",1789634243]