CurrentCignaPolicy N/A

prior_authorization_form_medication

This is a payer-specific medication prior authorization request form used by Cigna to collect clinical, administrative, and billing information for requests for Zoladex (goserelin) implants and related dispensing/administration details. It guides submission routes, urgency, patient/provider identifiers, diagnosis selection, and specialty dispensing options.

Policy Summary

PayerCigna

Policyprior_authorization_form_medication

Policy CodePolicy N/A

Change TypeAdministrative form (no material clinical changes)

Effective Date

Next Review Date

Key ActionFax the completed form to (855) 840-1678 or submit online at covermymeds.com or via SureScripts; include all required asterisked fields, clinical answers, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this document is an administrative prior authorization form for Zoladex (goserelin) and contains instructions for form completion and submission.

2Zoladex strength options on form

8Pre-set diagnosis choices

5Submission pathways listed

Policy overview and scope

This is a payer-specific Cigna prior authorization request form for Zoladex (goserelin) implants used to collect clinical, administrative, and billing information needed for coverage review and to route dispensing to the preferred specialty pharmacy, Accredo. The form captures patient and provider identifiers, urgency, medication strength (Zoladex 3.6 mg or Zoladex 10.8 mg 3-month implant), dose/J-code/frequency, diagnosis selection, clinical details tied to diagnosis, dispensing source options (including Accredo, prescriber office stock, retail, home infusion, or other), facility/dispensing details, and prescriber attestation/signature. Document type: administrative. Coverage stance: informational.

Form completion and required elements

The prior authorization request will be processed only if required fields (asterisked) are completed; urgency affects review timeframe.

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Documentation Required

Submit completed prior authorization form

Fax the completed prior authorization form to (855) 840-1678 or submit online at covermymeds.com or via SureScripts. Include all required asterisked (*) patient and provider fields, complete clinical answers, and the prescriber signature so the form can be processed and responded to via fax.

Fax number: (855) 840-1678
Online submission: covermymeds.com or via SureScripts
Include all asterisked (*) fields (e.g., Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, Date of Birth, Patient Street Address)
Include clinical answers and prescriber signature

Prior Authorization

Urgent request procedure

For urgent requests, fax the completed form and also call (800) 882-4462 to expedite review. When selecting Urgent, attest that applying the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function.

Call (800) 882-4462 in addition to faxing
Fax completed form to (855) 840-1678
Attest that standard review may seriously jeopardize the patient when marking Urgent

Dispensing, acquisition, and billing options

Dispensing and acquisition

Specify where medication will be obtained and how it will be billed/administered.

Select one or more

Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy).
Prescriber's office stock (billing on a medical claim form).
Retail pharmacy.
Home Health / Home Infusion vendor.
Other (specify).

ALL of the following

Provide facility and/or doctor dispensing and administering medication details if applicable (Facility Name, State, Tax ID#, Address).
Indicate whether the requested medication is for a chronic or long-term condition requiring lifelong therapy (Yes/No).

Billing Rule

Specialty pharmacy option — Accredo

Accredo is Cigna's nationally preferred specialty pharmacy. Medication orders can be placed with Accredo via e-prescribe, fax, or verbal. Providers choosing Accredo should use the Accredo contact information provided on the form when submitting orders.

Accredo is Cigna's nationally preferred specialty pharmacy
Order methods: e-prescribe, Fax (888.302.1028), Verbal (866.759.1557)
Providers using Accredo should use the Accredo contact info on the form

OpenPayer

prior_authorization_form_medication

Policy overview and scope

Form completion and required elements

Dispensing, acquisition, and billing options

Codes referenced on the form

Actions required by providers

Definitions

Document revision history