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 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:
Diagnosis related to use:
[For pain medications only]: Does the patient have a terminal illness? Yes No
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
this drug, including any intolerances or adverse reactions your patient experienced:
Drug Name
Dates taken & how long
Documented results, including intolerances/adverse
reactions the patient experienced
(if no to any question above) Is your patient able to use any other alternatives for this diagnosis? Yes No
Fax completed form to: (855) 840-1678
If this is an URGENT request, please call (800) 882-4462
(800.88.CIGNA)
(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.)
Save Time! 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 call us to expedite the request. View our Prescription Drug List and Coverage Policies online at cigna.com.
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“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 subsidiaries and not by Cigna Corporation. Such operating
subsidiaries include, for example, Cigna Health and Life Insurance Company and Cigna Health Management, Inc.
Address: Cigna Pharmacy Services, PO Box 42005,
Phoenix AZ 85080-2005
