Blank Cigna And Remicade Template

The Cigna and Remicade Form is a critical document required for obtaining prior authorization for the medication Remicade (infliximab). This form emphasizes the importance of providing complete and accurate information to prevent delays in processing requests. Individuals seeking approval for this treatment should fill out the form thoroughly and submit it promptly by clicking the button below.

Article Guide

The Cigna and Remicade Prior Authorization Form is a crucial document for healthcare providers seeking authorization for the use of Remicade (infliximab) for patients suffering from various autoimmune and inflammatory conditions, such as rheumatoid arthritis and Crohn’s disease. This form requires comprehensive information, including patient demographics, diagnosis, and prior treatment history. Error in completion can lead to delays or denials, making it essential to fill out every section diligently. Key details requested include the provider’s information, patient’s weight, treatment dosages, and previous responses to Remicade therapy or other medications. Additionally, providers must indicate where the medication will be dispensed and whether their fax machine is secure for sensitive information. There are also specific questions regarding previous treatments’ efficacy and contraindications, tailored to each condition. After submission, typical response times are between two to four business days, though urgent requests can be expedited by contacting Cigna Pharmacy Services directly. It’s vital to consult Cigna’s online resources for coverage positions and further guidelines.

Form Sample

Pharmacy Services

Phone: (800)244-6224

Fax: (800)390-9745

CIGNA HealthCare Prior Authorization Form

- Remicade (infliximab) -

Notice: Failure to complete this form in its entirety may result in delayed

processing or an adverse determination for insufficient information.

PROVIDER INFORMATION

PATIENT INFORMATION

* Provider Name:

**Due to privacy regulations we will not be able to

respond via fax with the outcome of our review unless all

Specialty:

* DEA or TIN:

asterisked (*) items on this form are completed**

Office Contact Person:

* Patient Name:

Office Phone:

* CIGNA ID:

Office Fax:

* Date Of Birth:

* Is your fax machine kept in a secure location?

Yes

* Patient Street Address:

* May we fax our response to your office?

Yes

Office Street Address:

City

State

Zip

City

State

Zip

Patient Phone:

Medication requested:

Remicade (infliximab) 100mg vial		Other (please specify):
Dose and Quantity:	Duration of therapy:			J-Code:
Frequency of administration:

Where will this medication be obtained?
CIGNA Tel-Drug (CIGNA's nationally preferred specialty pharmacy)*			Retail pharmacy
Prescriber’s office stock (billing on a medical claim form)			Home Health / Home Infusion vendor
Other (please specify):
*If you wish to order this medication from CIGNA Tel-Drug, please call 1-800-351-3606 for an order form.

Diagnosis related to use (please specify):
Rheumatoid Arthritis		Psoriatic Arthritis		Active Ankylosing Spondylitis
Chronic Plaque Psoriasis		Ulcerative Colitis		Crohn’s disease
Fistulizing Crohn’s disease		Inflammatory Bowel Disease Arthritis		Other (please specify):
What is the patient’s current weight?
Has this patient been on Remicade in the past?		Yes	No
If YES, what was the previous dosage?
Does the patient have history of beneficial clinical response to Remicade (infliximab) therapy?					Yes	No

Psoriatic or Reactive Arthritis:
Does patient have evidence of failure, intolerance or contraindication to Methotrexate therapy?					Yes	No

Rheumatoid Arthritis:
Will this medication be used in combination with Methotrexate therapy?			Yes		No

Please indicate if the patient has had evidence of failure, inadequate response, intolerance or contraindication to any of the following

disease-modifying anti-rheumatic drugs (DMARDs). Please check all that apply:
Methotrexate	Azathioprine	Gold	Hydroxychloroquine
Penacillamine	Sulfasalazine	Other (please specify):

(Continued on page 2)

CIGNA HealthCare Prior Authorization Form – Remicade – Page 1 of 2

If YES, please specify which medications:

Which of the following methods was used to measure the patient’s disease progression PRIOR to therapy on Remicade? (Check all that apply):

Health Assessment Questionnaire Disease Index (HAQ-DI)	Visual Analogue scale (VAS)
Likert scales of global response to pain by the patient/doctor	Global Arthritis Score (GAS)
Clinical Disease Activity Index (CDAI)	Simplified Disease Activity Index (SDAI)
Progression of radiographic damage of involved joints	Disease Activity Scale (DAS) score

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

Elevation of ESR (> 28 mm/hr), or C-reactive protein (CRP) (2x the upper limit of normal)

Other (please specify) :

If this is a request for CONTINUED THERAPY (after at least 16 weeks of treatment), has the patient shown beneficial response to treatment with Remicade based on any of the following measurements? (Check all that showed a beneficial response to Remicade therapy):

Health Assessment Questionnaire Disease Index (HAQ-DI)	Visual Analogue scale (VAS)
Likert scales of global response to pain by the patient/doctor	Global Arthritis Score (GAS)
Clinical Disease Activity Index (CDAI)	Simplified Disease Activity Index (SDAI)
Disease Activity Scale (DAS) score	ESR or C-reactive protein (CRP)

Disease Activity Score based on 28-joint evaluation (DAS28) score Disease Activity Scale (DAS) score

At least a 20% improvement according to ACR 20% response criteria

Other (please specify) :

Chronic Plaque Psoriasis:

Does the patient have history of beneficial clinical response to Remicade (infliximab) therapy?

Is the patient a candidate for systemic therapy?

Is the severity great enough that the patient is a candidate for Photo Therapy?

Is this a request for a renewal of a previously granted authorization?

If YES, please document improvement since beginning therapy:

Yes

Crohn’s Disease:

Has the patient had failure, contraindication, or intolerance to conventional therapies such as aminosalicylate, corticosteroids, or immunomodulators?

Yes No

Did the patient have a failure or intolerance to adalimumab (Humira) therapy?

Yes

Fistulizing Crohn’s Disease:

How long have fistulas persisted?

Inflammatory Bowel Disease Arthritis:

Has the patient had failure, contraindication, or intolerance to sulfasalazine, azathioprine, steroids, or, methotrexate?

Yes

Ankylosing Spondylitis:

Has the patient had failure, contraindication, or intolerance to non-steroidal anti-inflammatory drugs (NSAIDs)?

Yes

Ulcerative colitis:

Has the patient had failure, contraindication, or intolerance to conventional therapies such as corticosteroids (e.g, prednisone, methylprednisolone), 5-aminosalicylic acid agents (e.g., sulfasalazine, mesalamine, balsalazide), or immunosuppressants (e.g., azathioprine, cyclosporine, 6-mercaptopurine)?

Yes

If YES, please specify which medications:

Additional pertinent information:

CIGNA HealthCare’s coverage position on this and other medications may be viewed online at:

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions

Please fax completed form to (800)390-9745.

Our standard response time for prescription drug coverage requests is 2-4 business days. If your request is urgent, it is important that you call Pharmacy Services to expedite the request. View our formulary on line at http://www.cigna.com.

“CIGNA Pharmacy Management” or “CIGNA HealthCare” refer to various operating subsidiaries of CIGNA Corporation. Products and services	V 041610

are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, Tel-
Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., and HMO or service company subsidiaries of CIGNA Health Corporation.

CIGNA HealthCare Prior Authorization Form - Remicade - Page 2 of 2

⇩ PDF

Document Specifications

Fact Name	Description
Purpose	This form is used to request prior authorization for the medication Remicade (infliximab), essential for certain autoimmune conditions.
Provider and Patient Information	The form requires complete information about both the provider and the patient to avoid processing delays or adverse determinations.
Submission Methods	Completed forms must be faxed to (800)390-9745, and alternate methods of communication can affect response time.
Response Time	Ninety-eight percent of coverage requests will receive a response within 2-4 business days if submitted correctly.
Additional Information	CIGNA's coverage position can be accessed online for more details about the medication and other related services.

Steps to Filling Out Cigna And Remicade

Completing the Cigna and Remicade form requires careful attention to detail. Make sure to fill out all required fields to prevent delays in processing. Follow these steps to ensure that your form is correctly completed.

Enter the provider's name and specialty in the designated sections.
Provide the DEA or TIN number for the provider.
List the office contact person along with their office phone and fax numbers.
Fill in the patient's information including their full name, CIGNA ID, date of birth, street address, city, state, zip code, and phone number.
Indicate whether the fax machine is secure and whether a response can be faxed to your office.
Specify the medication requested as Remicade (infliximab) and fill in the dose, quantity, duration of therapy, J-code, and frequency of administration.
Indicate where the medication will be obtained (e.g., retail pharmacy, prescriber’s office stock).
Provide a detailed diagnosis related to the use of Remicade.
Enter the patient’s current weight.
Answer whether the patient has previously used Remicade and, if so, specify the previous dosage.
Indicate if there has been a beneficial clinical response to past Remicade therapy.
For specific conditions, answer additional questions about treatment history, such as failure, intolerance, or contraindication to other medications.
Document the methods used to measure the patient's disease progression prior to therapy.
If applicable, check if the patient has shown a beneficial response to treatment after at least 16 weeks.
Provide any additional pertinent information regarding the treatment.
Once the form is complete, fax it to (800)390-9745.

Be mindful of the standard response time, which is usually within 2-4 business days. For urgent requests, contact Pharmacy Services directly to expedite the process.

More About Cigna And Remicade

What is the purpose of the Cigna and Remicade form?

The Cigna and Remicade form is used to request prior authorization for the medication Remicade (infliximab). This form ensures that all necessary information is gathered to facilitate the approval process. It helps determine whether coverage will be granted based on the patient’s medical history and treatment plans. Completing the form accurately and in full is crucial to avoid delays or denials due to incomplete information.

Who needs to fill out the Cigna and Remicade form?

The form must be completed by the healthcare provider overseeing the patient's treatment. This includes physicians or specialists who have recommended Remicade for their patients. It is essential that all required fields, marked with an asterisk, are filled out to ensure the timely processing of the authorization request.

What information is required on the form?

Several key details are necessary for the authorization request. These include patient information such as the patient’s name, CIGNA ID, date of birth, and diagnosis. Provider information is also required, including the provider's name, contact details, and specialty. Additionally, specifics about the medication requested, dosage, duration of therapy, and the patient's treatment history with Remicade must be provided. This comprehensive information is critical for the assessment of the request.

How long does it take to process the authorization request?

Typically, Cigna aims to process authorization requests for prescription drugs within 2 to 4 business days. However, if the request is urgent, providers should directly contact Pharmacy Services to expedite the process. It is important for both providers and patients to factor in this timeline when planning for treatment.

What happens if I do not complete the form fully?

Failure to fill out the Cigna and Remicade form entirely can lead to significant delays in processing the authorization request. Incomplete information may result in an adverse determination due to insufficient data. To avoid any interruptions in care, ensure that every mandatory field is addressed thoroughly before submission.

Common mistakes

Incomplete Information: Failing to fill out all required fields marked with an asterisk (*) can lead to delays or denials of your request. Ensure all necessary sections are complete.
Incorrect Patient Details: Double-check the patient's information, including their CIGNA ID and date of birth. Even small errors can cause processing issues.
Missing Diagnosis Code: It’s important to specify the correct diagnosis related to the treatment request. Not providing this can result in insufficient information and processing delays.
Failure to Document Previous Treatments: If the patient has been on Remicade or other therapies before, be sure to include details about previous dosages and responses. This is critical for evaluating the request.

Documents used along the form

When working with the Cigna and Remicade form, it's helpful to be aware of other documents and forms that may be used alongside it. Each of these serves a unique purpose to facilitate smoother communication and approval processes related to patient care and medication management. Below is a brief overview of four common forms that often accompany the Cigna and Remicade submission.

Prior Authorization Request Form: This form is essential for obtaining approval from an insurance provider before a specific treatment or medication is dispensed. It includes information about the patient’s medical condition and previous treatments.
Clinical Assessment Form: Used by healthcare providers, this document helps assess a patient’s eligibility for certain therapies based on their medical history and current health status. It may include details about previous responses to treatment.
Medication History Form: This form gathers a comprehensive account of a patient's previous medications, including any side effects or issues experienced. It ensures the healthcare professional has all necessary information to make informed decisions.
Patient Consent Form: This document is crucial for ensuring that patients understand and agree to the treatment plan. It typically outlines the risks, benefits, and alternatives related to the proposed therapy.

Each form plays a vital role in managing patient care effectively. Be sure to review these documents carefully to ensure all necessary information is accurately captured for the best outcomes in treatment and insurance coverage.

Similar forms

The Cigna and Remicade prior authorization form shares similarities with the General Prior Authorization Request form. Both documents serve the purpose of verifying medical necessity before a drug can be prescribed. They require detailed patient information and justification for the requested therapy. By gathering specific data, such as previous treatments and outcomes, each form aims to streamline the process of obtaining necessary medications, ensuring that patients only receive therapies appropriate for their conditions.

Another document that resembles the Cigna and Remicade form is the Healthcare Provider Referral form. Like the prior authorization form, this document collects comprehensive information from healthcare providers regarding a patient's health status and treatment history. It emphasizes the need for provider collaboration to deliver optimal care. Both forms highlight essential information such as diagnosis and treatment plans, ensuring patients receive continuous and adequately informed care regardless of the healthcare setting.

The Medication Management Form also relates closely to the Cigna and Remicade form. Healthcare providers fill out this document to assess a patient’s medication history, adherence, and potential side effects. Like the prior authorization form, it aims to gather extensive insight into the patient's current treatment regimen. This way, providers can make informed decisions about prescribing new medications or adjusting existing therapies to better suit patient needs.

Similarly, the Specialty Drug Prior Authorization Form serves a comparable function. This document focuses specifically on high-cost specialty medications like Remicade, gathering information needed to determine coverage. Notably, both forms require evidence of a patient’s previous treatment attempts or failures. Through this rigorous assessment, they aim to ensure that patients only receive medications that hold the promise of effective treatment, reducing wasted costs and enhancing outcomes.

Finally, the Formulary Exception Request form resonates with the Cigna and Remicade form due to its purpose of seeking insurance approval for medications not typically covered due to formulary limitations. Both forms necessitate a thorough explanation of why a particular drug is essential for the patient's treatment plan. Furthermore, they promote transparency in the approval process, allowing healthcare providers to advocate effectively for their patients when faced with medication restrictions.

Dos and Don'ts

When filling out the Cigna and Remicade form, being attentive and thorough is essential to avoid delays. Here are eight things to keep in mind:

Do ensure all required fields are completed. Missing information can lead to denial or delays.
Do provide accurate patient information. Double-check details such as the patient's name, date of birth, and CIGNA ID.
Do specify the medication clearly. Indicate whether you are requesting Remicade or another treatment option.
Do confirm the medication's administration frequency. Include the dosage and duration as well.
Don't skip the diagnosis section. Including relevant diagnoses helps support the request.
Don't leave out previous therapy details. Indicate any past use of Remicade and patient responses.
Don't forget to ask about faxing permissions. Clarify whether to send the response back to the office via fax.
Don't ignore the additional documentation requirements. Some conditions may need supporting records.

Misconceptions

1. Completing the Form is Optional

Some people believe that filling out the Cigna and Remicade form is optional. This is incorrect. It is essential to complete the form fully. Incomplete forms may lead to delays or denials.

2. Only Certain Providers Can Submit the Form

There is a misconception that only specific healthcare providers can submit the authorization form. In reality, any qualified healthcare provider can submit it on behalf of their patient, as long as they have the necessary information.

3. Faxing Is the Only Way to Submit

Many assume that faxing the form is the only submission method. However, providers may also send the form via secure electronic methods in line with privacy regulations.

4. Urgent Requests Are Treated Like Regular Requests

Some individuals think that urgent requests are handled just like standard requests. This is misleading. Urgent requests are prioritized. Calling Pharmacy Services can expedite this process.

5. Past Denials Do Not Affect Current Requests

People often believe that prior denials do not influence new requests. The reality is former denials can impact the current authorization process. Clear documentation of changes in the patient’s condition is necessary.

6. All Medications Require Prior Authorization

There is a common belief that all medications available through Cigna need prior authorization. Not every medication requires this; it depends on the specifics of the patient's treatment plan and the drug in question.

Key takeaways

Complete All Sections: Ensure that every required field, marked with an asterisk (*), is filled out to avoid delays in processing your request.
Provider and Patient Information: Clearly provide accurate details about both the healthcare provider and the patient. This includes the provider's name, specialty, and the patient's CIGNA ID and address.
Medication Details: Specify the requested medication, dosage, and frequency of administration. Indicate where the medication will be obtained, such as CIGNA's specialty pharmacy or a retail pharmacy.
Diagnosis Specification: Clearly state the diagnosis for which Remicade is being requested. Options include various types of arthritis and inflammatory bowel diseases.
Assess Prior Therapies: Indicate any previous medications the patient has taken and whether they have shown a beneficial response or experienced any intolerances.
Response Time: Expect a standard response time of 2-4 business days after submitting the form. If the request is urgent, contacting Pharmacy Services directly can expedite the decision process.