CurrentCignaPolicy N/A

Medication Prior Authorization Form (Pharmacy Prior Authorization)

A Cigna pharmacy prior authorization form governing requests for coverage of prescription medications; used by prescribers to submit clinical and administrative information to obtain prior authorization for medications.

Policy Summary

PayerCigna

PolicyMedication Prior Authorization Form (Pharmacy Prior Authorization)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via fax to 855-840-1678 or online at CoverMyMeds; call 800-882-4462 for urgent requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 business daysturnaround

855-840-1678fax

800-882-4462urgent phone

CoverMyMedsonline

Provider Submission & Documentation Requirements

Prior Authorization

Submission method and urgent requests

Fax completed form to: (855) 840-1678. Save Time! Submit Online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. If this is an URGENT request, please call (800) 882-4462 (800.88.CIGNA).

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
EHR: Submit via SureScripts
Urgent phone: (800) 882-4462

Denial Risk

Timeliness and completeness risks

Most pharmacy prior authorizations are completed within two business days unless additional information is required from the provider. Incomplete or missing required fields may delay review and result in requests for more information; urgent requests should be followed up by phone to expedite processing.

Policy Summary

PayerCigna

PolicyMedication Prior Authorization Form (Pharmacy Prior Authorization)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via fax to 855-840-1678 or online at CoverMyMeds; call 800-882-4462 for urgent requests.

SourceLink

On This Page

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Documentation Required

Required documentation and form fields

Complete all required patient and prescriber fields on the medication prior authorization form. Fields marked with an asterisk (*) must be completed for the form to be processed. Include medication details, strength, dosing schedule, quantity, duration of therapy, ICD-10 diagnosis, and whether the medication is for a chronic/long-term condition.

Required patient fields: Patient name, Cigna ID, date of birth, patient address, patient phone
Required prescriber fields: Physician name, specialty, DEA/NPI/TIN, office contact, office phone, office fax, office address
Medication details: name, strength, dosing schedule, quantity, duration of therapy, ICD-10
Clinical fields: urgency (standard vs urgent), whether medication is for chronic/long-term condition, additional pertinent clinical information and relevant lab values
Attestation: Prescriber signature and date required

Step Therapy

Step/alternative therapy documentation

Document trials of generic and other alternative therapies. Provide manufacturer, dates taken and duration, and documented results including intolerances or adverse reactions. If alternatives were not tried, provide reasons why the patient cannot use available alternatives and list any other alternative treatments tried with dates and outcomes.

State whether patient received generic alternatives: Yes / No / No generic available
If yes, indicate whether multiple manufacturers were tried: Yes / No / Unavailable
For each trial provide: drug name, manufacturer, dates taken & duration, documented results and any intolerances/adverse reactions
If other alternatives tried, provide same details (drug name, dates/duration, results/adverse reactions)
If alternatives not an option, provide clinical justification why patient is unable to use available alternatives

Policy Background

This document is an administrative Medication Prior Authorization Form used by prescribers to provide the clinical and administrative details required to assess medical necessity for prescription drugs. The form collects patient and prescriber identifiers (asterisked fields are required), medication name/strength/dosing, duration, quantity, ICD-10 diagnosis, and whether the medication is for a chronic or long-term condition. It also requests documentation of prior medication trials, including generic alternatives and other alternative treatments, with manufacturer, dates taken, duration, and documented results or intolerances, plus any additional pertinent clinical information or lab values and a prescriber attestation with signature and date. (Required fields and examples are on the form.)

Completed forms may be submitted by fax to (855) 840-1678 or online via www.covermymeds.com (also available via SureScripts in participating EHRs). If the request is urgent—that is, applying the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function—providers should call (800) 882-4462 to expedite review.

Most pharmacy prior authorizations are completed within two business days when all required information is provided. Incomplete forms or missing required fields may delay or prevent approval and may trigger requests for additional medical information, so ensure all asterisked items and documentation of prior trials and clinical rationale are included when submitting.

Definitions

Urgent — definition / quick reference

DefinitionUrgent — a request marked 'Urgent' indicates that applying the standard review time frame may seriously jeopardize the customer's life, health, or ability to regain maximum function.

How to indicateCheck the 'Urgent' box on the form under 'Urgency'.

Attestation requiredBy checking 'Urgent' the submitter attests to the condition described on the form (serious jeopardy to life, health, or function).

Information to includeProvide medication name, strength, dosing schedule, duration of therapy, quantity, and ICD-10 diagnosis when submitting an urgent request.

ContextUse urgent only when standard review time frames would seriously jeopardize the patient; otherwise select 'Standard'.