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It covers urgency selection, medication specifics (name, strength, dosing schedule), duration, quantity, and ICD10 diagnosis information. The form also requests clinical context on whether the medication is for a chronic or long-term condition and gathers data on alternative medications, including generic and other treatment trials with documented results. 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Items marked with an asterisk must be completed to allow faxed outcome review.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the form handle urgent versus standard requests?",{"text":113,"@type":109},"It includes an Urgency section where standard or urgent can be selected. Choosing urgent requires attesting that the standard review time frame may seriously jeopardize the customer’s life, health, or ability to regain maximum function.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation is needed for alternative medications and treatments?",{"text":117,"@type":109},"The form asks whether the patient previously received generic alternatives and other treatment options for the diagnosis. For each trial, it requests manufacturer name, dates taken and duration, and documented results including any intolerances or adverse reactions, plus reasons if alternatives cannot be used.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283757,1790509101,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},3985741905716,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Fax completed form to: (855) 840-1678  \nIf this is an URGENT request, please call (800) 882-4462  \n(800.88.CIGNA)  \nMedication Prior Authorization Form  \n\n| PHYSICIAN INFORMATION |  |  |  |  | PATIENT INFORMATION |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| * 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. * |  |  |  |  |\n| Specialty: |  | * DEA, NPI or TIN: |  |  |  |  |  |  |\n| Office Contact Person: |  |  |  | * Patient Name: |  |  |  |  |\n| Office Phone: |  |  |  | * Cigna ID: |  |  | * Date of Birth: |  |\n| Office Fax: |  |  |  | * Patient Street Address: |  |  |  |  |\n| Office Street Address: |  |  |  | City: |  | State: |  | Zip: |\n| City: | State: |  | Zip: | Patient Phone: |  |  |  |  |\n| Urgency:\u003Cbr> Standard  Urgent (In checking this box, I attest to the fact that applying the standard review time frame may\u003Cbr>seriously jeopardize the customer’s life, health, or ability to regain maximum function) |  |  |  |  |  |  |  |  |\n| Medication requested: (please specify name, strength, and dosing schedule)\u003Cbr>Duration of therapy: Quantity: ICD10: |  |  |  |  |  |  |  |  |\n| Is the requested medication for a chronic or long-term condition for which the prescription medication may be necessary for the life of\u003Cbr>the patient?  Yes  No |  |  |  |  |  |  |  |  |\n| Diagnosis related to use: |  |  |  |  |  |  |  |  |\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\u003Cbr>Drug Name Dates taken & how long Documented results, including intolerances/adverse reactions the patient experienced\u003Cbr>this drug, including any intolerances or adverse reactions your patient experienced: |  |  |  |  |  |  |  |  |\n\n\n| (if no to any question above) Is your patient able to use any other alternatives for this diagnosis?  Yes  No\u003Cbr>(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| 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\u003Cbr>information reported on this form.\u003Cbr>Prescriber Signature:  Date:  |\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 cal","cbCairob1qzZkcLy","https://ap.wps.com/l/cbCairob1qzZkcLy","pdf",59672,"English","# Medication Prior Authorization Form\n## Physician Information\n## Patient Information\n## Medication and Diagnosis Details\n## Alternative Medications and Treatments\n## Attestation and Signature","[{\"question\":\"What information must be completed for the physician and patient sections?\",\"answer\":\"The form requires physician details (including specialty and DEA/NPI or TIN where applicable) and patient details such as name, Cigna ID, and date of birth, along with address and contact information. Items marked with an asterisk must be completed to allow faxed outcome review.\"},{\"question\":\"How does the form handle urgent versus standard requests?\",\"answer\":\"It includes an Urgency section where standard or urgent can be selected. Choosing urgent requires attesting that the standard review time frame may seriously jeopardize the customer’s life, health, or ability to regain maximum function.\"},{\"question\":\"What documentation is needed for alternative medications and treatments?\",\"answer\":\"The form asks whether the patient previously received generic alternatives and other treatment options for the diagnosis. For each trial, it requests manufacturer name, dates taken and duration, and documented results including any intolerances or adverse reactions, plus reasons if alternatives cannot be used.\"}]","Medication Prior Authorization Form | PDF",1789618805]