CurrentCignaPolicy v061025

Patient information and prior authorization form for specialty drug medications

This document is a Cigna patient information and prior authorization submission form used by providers to request coverage for specialty or compounded medications and to provide required patient, prescribing, and medication details. It affects prescribing clinicians, office staff, and pharmacies submitting prior authorizations to Cigna.

Policy Summary

PayerCigna

PolicyPatient information and prior authorization form for specialty drug medications

Policy CodePolicy v061025

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionFax a completed prior authorization form with all required fields (patient and prescriber identifiers, diagnosis, medication details, site-of-care, and prior treatment history) to Cigna for coverage review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax (855) 840-1678submission fax number

(800) 882-4462urgent request phone number

Accredopreferred specialty pharmacy

v061025policy/form id

2 business daystypical PA turnaround

Coverage and Submission Criteria

Submission and completeness criteria

Coverage review is initiated when the provider submits a completed prior authorization form with required fields filled.

Form completeness and patient/prescriber data: All required asterisked fields must be completed, including patient identifiers (Cigna ID, patient name, date of birth, patient street address), prescriber identifiers (DEA, NPI or TIN), and office contact information.

Incomplete asterisked (*) required fields will prevent Cigna from responding via fax with the outcome of review.

Medication and clinical details: Provide medication name, strength, and dosing schedule; diagnosis with ICD-10 code; duration of therapy; and clinical rationale or pertinent clinical information (e.g., relevant lab values).

Include additional clinical documentation when relevant to support medical necessity.

Site of care and dispensing: Indicate where the medication will be obtained (e.g., Accredo Specialty Pharmacy, prescriber's office stock, retail pharmacy, home health/home infusion) and where it will be administered (patient's home, physician's office, hospital outpatient, or other).

Policy Summary

PayerCigna

PolicyPatient information and prior authorization form for specialty drug medications

Policy CodePolicy v061025

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Provider Submission Requirements and Required Documentation

Prior Authorization

Prior Authorization Submission Requirements

Prior authorization submission requirements — When submitting a prior authorization request, the provider must specify urgency, the medication name with strength and dosing schedule, the source and administration site, and any additional clinical details to support medical necessity.

Specify urgency: Standard or Urgent (attestation required for Urgent)
Provide medication name, strength, and dosing schedule
Indicate where medication will be obtained (Accredo Specialty Pharmacy, prescriber office stock, retail pharmacy, home health/home infusion vendor, or other)
Identify facility/doctor dispensing and administering medication and provide facility name, state, tax ID, and full address
State where drug will be administered (patient's home, physician's office, hospital outpatient, or other) and whether patient is candidate for redirection to a lower-intensity setting

Step Therapy

Prior Therapy Documentation

Prior therapy documentation required — Providers must document prior Prescription Drug List (PDL) alternatives tried, including the name of each alternative, length of trial, and whether samples were given. Include clinical rationale for discontinuation or failure of each alternative.

List Prescription Drug List alternatives tried
For each alternative, include trial length (e.g., number of weeks/months) and whether samples were provided
Provide clinical reason for failure or intolerance for each prior therapy

Documentation Required

Required Patient and Prescriber Identifiers

Patient and prescriber identifiers required — To complete review, providers must supply all patient and prescriber identifiers: Cigna ID, patient date of birth, patient street address, and prescriber DEA, NPI or TIN. Also include diagnosis with ICD-10 code, duration of therapy requested, and relevant contact information.

Patient identifiers: Cigna ID, Date of Birth, Patient Name, Patient Street Address, City, State, Zip, Patient Phone
Prescriber identifiers: Physician name, Specialty, DEA, NPI or TIN, Office contact person, Office phone, Office fax, Office street address, City, State, Zip
Clinical details: Diagnosis and ICD-10 code, Duration of therapy requested, Indication if chronic/long-term therapy

Denial Risk

Complete Required Fields to Receive Outcome

Incomplete forms may delay response — If required asterisked fields are not completed (including patient identifiers and required prescriber information), Cigna may be unable to respond via fax with the outcome of the review.

Ensure all asterisked (*) items on the form are completed to receive faxed outcome
Missing required fields (e.g., Cigna ID, DOB, prescriber DEA/NPI/TIN) can prevent timely review and response

OpenPayer

Patient information and prior authorization form for specialty drug medications

Coverage and Submission Criteria

Diagnosis and Compound Identifiers

Provider Submission Requirements and Required Documentation

Administration Location Requirements