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The Cigna Tel Drug Fax form is an essential tool for patients who seek to manage their prescriptions effectively. Designed to streamline the ordering process, the form requires clear and accurate information to avoid delays in processing. Users must complete specific steps, including providing insurance cardholder details, selecting a shipping method, and submitting payment information. Each section is carefully crafted to ensure completeness, such as noting allergies and health conditions that might affect medication choices. The form emphasizes the importance of original prescriptions, as copies will not be accepted. Additionally, it allows for both new prescriptions and refill requests, catering to the diverse needs of patients. Proper adherence to the instructions will facilitate a smoother experience for those utilizing this service. Moreover, patients have the option to expedite shipping or select standard delivery, depending on urgency and cost considerations.

Form Sample

CIGNA Tel-Drug Prescription Order Form

 

By submitting this form you are representing that the information provided is correct.

 

.

 

 

. Please print all information clearly with black or blue ink.

 

.

Please complete Steps 1, 2, 3 and 4. Then complete Step 5 and/or 6 as needed.

 

Incomplete information may delay processing.

 

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Please enclose payment method and original prescription(s) only. Copies of prescription(s) will not be accepted.

505

Please do not staple any items to this form.

STEP 1: INSURANCE CARDHOLDER INFORMATION

Cardholder ID #

 

 

 

Cardholder’s

 

 

 

 

 

 

TEMPORARY SHIPPING ADDRESS

 

(SEE INSURANCE CARD)

Full Name

 

 

 

 

 

 

 

 

 

(FOR THIS ORDER ONLY)

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

In Care of Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

 

Zip Code (+ 4)

Temp Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home (

)

 

 

Alternate

(

)

 

 

 

 

 

Temp City

 

 

Temp

 

Phone

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder’s

 

 

 

Cardholder’s

 

 

 

 

 

 

Temp Zip Code

 

Temp Phone

 

Employer

 

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: SHIPPING

 

 

 

 

 

 

 

 

 

STEP 3: PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If this section is left blank, Standard Shipping will be used.

Refrigerated shipments will be expedited at no additional cost.

Check ( ) the box for the Shipping Method of your choice. You are responsible for the cost of SPECIAL SHIPPING.

Shipping Method

# of Days

Cost

Standard Shipping

Standard Delivery

$0.00

USPS PRIORITY MAIL

2-3 Days

$5.25

USPS EXPRESS MAIL

Overnight

$17.95

FEDERAL EXPRESS

Overnight

$17.95

Failure to include complete payment information may delay or prevent shipment of order.

Check ( ) the box for the Payment method of your choice.

Enclosed is a check or money order made payable to CIGNA Tel-Drug.

I authorize CIGNA Tel-Drug to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsurance and/or deductible(s), payments due for any medications not covered under my benefit plan, plus any special shipping costs.

Complete credit card information is required for each order.

Check ( ) credit card type and enter corresponding credit card information below.

UPS OVERNIGHT

Overnight (by 12:00 noon)

$17.95

UPS SAVER

Overnight (by 7 pm)

$16.95

SPECIAL SHIPPING expedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject to change by carrier without prior notification and may vary depending on weight and zone.

American Express

Discover

MasterCard

VISA

Credit

Card #

Expiration

/

Date (MM/YY)

 

 

Name on

 

Credit Card

 

I would like to pay full price for the medication(s) listed below. Do not bill my insurance.

Medication Name and Strength

Medication Name and Strength

584001 Rev. 05/2006

Don’t forget to complete the remaining steps on the reverse side.

STEP 4: ALLERGIES & HEALTH CONDITIONS

Please complete this section every time a medication is ordered.

Patient’s Full Name

Male /

Birth Date

Include nickname, Jr./Sr., etc.

Female

 

 

 

 

 

/

/

 

 

/

/

 

 

/

/

 

 

/

/

 

 

 

 

None

Aspirin

Cephalosporins

Codeine

Erythromycin

Ibuprofen

Penicillin

Sulfa

If no allergies are checked (

), for new customers this

indicates no known allergies

and for existing customers

this indicates no change.

 

 

 

 

Other Allergies

 

Major Health Conditions

 

 

 

 

STEP 5: REFILL PRESCRIPTIONS

For your convenience, you can order refills by calling our automated system at 1.800.TEL.DRUG (835.3784) option 1 or by visiting us at mycigna.com . Do not include refills on this form that you plan to order by phone or Internet. Refills from other pharmacies should not be included on this form.

Patient’s Full Name

Birth Date

CIGNA Tel-Drug Rx Number

Medication Name and Strength

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

STEP 6: NEW PRESCRIPTIONS

PHARMACY LAW PERMITS PHARMACISTS TO SUBSTITUTE A LESS EXPENSIVE GENERICALLY EQUIVALENT MEDICATION FOR A BRAND NAME

MEDICATION UNLESS YOU OR YOUR PRESCRIBER INDICATE OTHERWISE. BY CHECKING (

) "BRAND ONLY", YOU MAY INCUR A HIGHER COST.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ( ) ONE

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Full Name

Birth Date

Fill

Do Not

Medication Name & Strength

 

( ) if

Prescriber’s/Physician’s

Prescriber’s/Physician’s

Now

Fill

 

Brand

Full Name

 

Phone Number

 

 

 

Now*

 

 

Only

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

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/

/

 

 

 

 

 

 

(

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/

/

 

 

 

 

 

 

(

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* By checking this option, you are indicating you do not want the prescription filled at this time. Please contact CIGNA Tel-Drug when the medication is needed.

Thank you for choosing CIGNA Tel-Drug.

You can call us at 1.800.TEL.DRUG (835.3784) or visit us at www.teldrug.com.

You can also write to us or mail this order form to CIGNA Tel-Drug, PO Box 1019, Horsham PA 19044.

At times it may be necessary to switch manufacturers on generic medications. This may cause a change in appearance (size, shape and/or color) of the medication.584001 (BACK) Rev. 05/2006 CIGNA Tel-Drug refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation.

Document Specifications

Fact Name Description
Form Purpose The Cigna Tel Drug Fax form is used to order prescription medications through Cigna Tel-Drug.
Required Information Participants must fill out personal information, prescription details, and payment options clearly to avoid delays.
Shipping Options Multiple shipping methods are available, including standard delivery and expedited services, with varying costs.
Payment Method Payment can be made through checks, money orders, or credit cards, and all necessary details must be included for processing.
Allergies Disclosure It is crucial that patients disclose any allergies or health conditions to ensure safe medication dispensing.
State-Specific Laws The form complies with pharmacy laws that allow pharmacists to substitute generic medications unless specified otherwise by prescriber or patient.

Steps to Filling Out Cigna Tel Drug Fax

Completing the Cigna Tel Drug Fax form requires careful attention to detail to ensure that your order is processed smoothly. Follow the steps outlined below to fill out each section correctly. Incomplete or unclear information can delay the processing of your requests.

  1. Step 1: Insurance Cardholder Information
    - Write your Cardholder ID number.
    - Fill in the temporary shipping address including full name, address, city, state, and zip code.
    - Add the email address and phone number of the cardholder.
    - Make sure to indicate the employer's information as necessary.
  2. Step 2: Shipping
    - Choose a shipping method based on your preference: Standard Shipping, USPS Priority Mail, USPS Express Mail, Federal Express, or UPS.
    - If applicable, write the number of days and cost for your chosen shipping option.
  3. Step 3: Payment
    - Select your payment method: check/money order or credit card.
    - If using a credit card, provide the credit card type, number, expiration date, and the name on the card.
    - If paying full price for medications, list the names and strengths of your medications.
  4. Step 4: Allergies & Health Conditions
    - Fill in the patient’s full name and birth date.
    - Indicate any allergies by checking the relevant boxes, or mark “none” if there are no known allergies.
    - List any major health conditions that apply to the patient.
  5. Step 5: Refill Prescriptions
    - Write the patient’s full name and birth date.
    - Include the CIGNA Tel-Drug Rx number and medication names and strengths for any refills.
  6. Step 6: New Prescriptions
    - Indicate whether you want the brand name medication by checking the appropriate box.
    - Fill in the patient’s full name, birth date, medication name and strength, and the prescriber’s information.

Make sure to double-check all entries before sending your form. Once complete, carefully enclose your original prescriptions and payment method, ensuring that nothing is stapled to the form. Now you are ready to submit your completed form to Cigna Tel-Drug for processing.

More About Cigna Tel Drug Fax

What is the Cigna Tel Drug Fax form used for?

The Cigna Tel Drug Fax form is a document that allows patients to order medications through Cigna's mail-order pharmacy service. It is essential for providing necessary information such as insurance details, payment methods, and prescription specifics to ensure a smooth order process.

How do I complete the form?

To complete the form, fill in the required steps—1 through 4—in clear handwriting using black or blue ink. Include your insurance information, shipping details, allergies, and health conditions. Steps 5 and 6 are for ordering refills or new prescriptions if needed. Make sure not to staple any documents and to enclose your original prescriptions along with the payment method.

What should I do if I make a mistake on the form?

If you make an error while filling out the form, you should complete a new form rather than trying to correct the mistake on the existing one. This helps avoid confusion and ensures that processing is not delayed due to unclear information.

What types of payment are accepted?

Cigna Tel Drug accepts various payment methods. You can pay by check or money order made out to Cigna Tel-Drug, or you can authorize billing to your credit card. If using a credit card, complete the credit card information section on the form carefully, including the type of card and expiration date.

How is shipping handled for orders?

Shipping options include standard, USPS Priority Mail, USPS Express Mail, Federal Express, and UPS. Standard shipping is free, while expedited methods have associated costs. If you want refrigerated medications, indicate that on the form, and it will be expedited at no extra charge. Be sure to specify your preferred shipping method to avoid delays.

What happens if I don’t provide complete information?

Providing incomplete information may cause delays in processing your order. Make sure to review the form carefully to double-check that all necessary fields are filled out completely. This includes your insurance details, payment method, and any allergy information.

How can I check the status of my order?

You can call Cigna Tel-Drug at 1.800.TEL.DRUG (835.3784) to ask about your order status. Alternatively, you can visit their website at mycigna.com for updates on your prescription orders.

Common mistakes

  1. Incomplete Information: Failing to fill out all required sections can lead to delays in processing the order. Ensure you complete all steps: 1 through 4, as well as any applicable steps 5 and 6.

  2. Illegible Writing: Using unclear handwriting makes it difficult for processing staff to read important information. It's best to print clearly using black or blue ink to avoid any miscommunication.

  3. Incorrect Shipping Method Selection: Inaccurately checking your preferred shipping method can result in unexpected delays. Read the options carefully and always confirm your selection before submitting the form.

  4. Missing Payment Information: Leaving the payment section blank can result in significant delays or cancellation of your order. Make sure to provide accurate payment details and choose your payment method appropriately.

  5. Not Following Instructions on Prescriptions: Including copies of prescriptions rather than the originals can result in rejection of the order. Always ensure to enclose the original prescription(s) only as specified in the instructions.

By avoiding these common mistakes, you can help ensure that your Cigna Tel Drug Fax form is processed efficiently and without unnecessary delays.

Documents used along the form

When dealing with medication orders and pharmacy services, a variety of forms accompany the Cigna Tel Drug Fax form. Each form has a specific purpose that ensures a smooth transaction and compliance with healthcare regulations. Below is a list of documents commonly used alongside the Cigna Tel Drug Fax form.

  • Insurance Verification Form: This form gathers insurance details to confirm coverage for medications. Proper completion ensures that patients understand their benefits and any out-of-pocket costs.
  • Prescription Transfer Form: Should a patient wish to transfer their prescription from one pharmacy to another, this form facilitates that process. It collects necessary information to ensure a seamless transfer.
  • Patient Medication History Form: This form is crucial for documenting a patient's prior medications, allergies, and health conditions. It helps pharmacists provide safer medication options and avoid adverse reactions.
  • Medication Refill Request Form: For those needing refills, this form simplifies the process. Patients can specify the medications needing refills and submit it to the pharmacy in a standardized way.
  • Authorization to Release Medical Information: This form allows healthcare providers to share a patient’s medical information with pharmacies or other healthcare entities. It ensures compliance with HIPAA regulations for privacy and confidentiality.
  • Drug Utilization Review Form: Pharmacists use this form to assess the appropriateness of prescribed medications. It helps identify potential drug interactions or contraindications, ensuring patient safety.
  • Financial Assistance Application: Patients who may struggle to afford medication can use this form to apply for financial support. It details the applicant's financial situation and helps determine eligibility for assistance programs.
  • New Patient Registration Form: When utilizing new pharmacy services, patients typically complete this form, providing essential information such as contact details and medical history to facilitate proper care and communication.

Each of these forms plays a vital role in the medication ordering process, ensuring clear communication between patients, pharmacies, and healthcare providers. Properly completing and submitting these documents can enhance patient care and streamline the overall experience.

Similar forms

The Prior Authorization Request Form is a crucial document used to obtain permission from an insurance provider before a specific medication can be dispensed. Like the Cigna Tel Drug Fax form, it requires detailed patient information, including insurance details and the requesting physician's contact information. The Prior Authorization Request often necessitates the submission of medical justification for the prescribed drug. This process ensures that the patient receives the medication deemed medically necessary while adhering to the insurance's policies, similar to verifying prescription details and payment methods in the Cigna fax form.

The Prescription Refill Request Form allows a patient to request refills of a current medication without a new consultation. It resembles the Cigna form by incorporating essential patient identification data and medication details. Patients often must provide their prescription number, dosage, and confirmation of their identity. The streamlined design aims to facilitate easy access to medication, akin to how the Cigna form organizes ordering prescriptions, refills, and payment in one process.

A Medication Order Form is typically used within healthcare facilities to document requests for medications through a standardized format. This document parallels the Cigna Tel Drug Fax form by requiring identification information for the patient and delivery specifications. Both forms provide clear instructions on completing necessary steps, ensuring that the medical team accurately processes medication requests without delays.

The New Patient Registration Form gathers vital information from new patients, including medical history and current medications. It shares similarities with the Cigna form regarding data collection and the emphasis on accuracy. Both forms underscore the importance of complete and correct information to ensure the proper response from the healthcare system, particularly in medication fulfillment.

The Claim Form is essential for patients seeking reimbursement for medical expenses from their insurance providers. Like the Cigna Tel Drug Fax form, it requires personal and insurance information to process claims efficiently. Each ensures that the necessary details are submitted for timely approval, highlighting the importance of accurate information to avoid payment delays.

The Patient Authorization Form grants healthcare providers permission to share patient information with third parties. Similar to the Cigna form, it necessitates clear patient identification and consent details. Both documents require signatures and provide instructions for completion, emphasizing the need for formal approval in all medical transactions.

A Specialty Drug Request Form is specifically used for medications that require special handling or are used for complex conditions. It resembles the Cigna Tel Drug Fax form through its need for patient demographic information and medical necessity documentation. The careful detailing in both forms facilitates the efficient management of prescriptions that fall under specific categories of care.

The Medication Therapy Management Form aids pharmacists in reviewing the patient's medications for potential issues. This form parallels the Cigna Tel Drug Fax form by requiring a comprehensive record of current prescriptions and patient health information. Both forms focus on ensuring the patient receives coordinated care by compiling information that aids in decision-making at the pharmacy level.

The Home Health Care Prescription Form is utilized when prescribing medications for home health services. Like the Cigna form, it demands clear information regarding patient care, prescription details, and health conditions. Both are designed to streamline the process of delivering essential medications, emphasizing the importance of clarity in aiding patient needs promptly.

The Immunization Record Form documents vaccination details for patients. It closely resembles the Cigna Tel Drug Fax form in providing structured sections for patient identification and medicine specifics. Both documents serve to ensure that vital health information is accurately tracked, contributing to the overall healthcare management experience.

Dos and Don'ts

Things You Should Do:

  • Print all information clearly using black or blue ink.
  • Complete all required steps (1 through 4) before moving on to steps 5 and 6.
  • Provide accurate and complete payment information to avoid delays.
  • Enclose the original prescription(s) only; do not send copies.
  • Check your entries for accuracy before submission.

Things You Shouldn't Do:

  • Do not staple any items to the form.
  • Avoid leaving any sections blank, as this may delay processing.
  • Do not include refills on this form if you plan to order them by phone or online.
  • Refrain from submitting multiple prescriptions without the correct details for each.
  • Do not forget to complete the remaining steps on the reverse side of the form.

Misconceptions

Misconceptions regarding the Cigna Tel Drug Fax form may lead to confusion and delays in processing prescriptions. Here are some common misunderstandings, explained for clarity.

  • It is not mandatory to provide insurance information. Some believe they can skip this step. However, providing accurate insurance data is critical for processing and billing.
  • Payment is optional if insurance is provided. Many assume that insurance covers everything. It's essential to understand that copayments, coinsurance, and deductibles may still apply, requiring a payment method even when insurance is used.
  • Submitting copies of prescriptions is acceptable. A common myth persists that copies can be submitted. Only original prescriptions are accepted, and attempting to include copies may cause unnecessary delays.
  • All medications can be refilled using this form. Some individuals think refill requests can be included. Instead, refills should be communicated via the dedicated phone line or online portal, not through the fax form.
  • Special shipping guarantees faster order processing. It's a misconception that paying for special shipping will expedite the order processing time. Special shipping only affects delivery, not the time it takes to process the order.
  • All allergies must be listed every time. A misunderstanding exists regarding allergy disclosure. Indicating "none" or checking known allergies is sufficient for returning customers, but new customers must provide complete allergy information.
  • Generic substitutions are always permitted. Some may think that brand-name medications will automatically be substituted with generics. However, if you specify "brand only," the pharmacist must honor that request, which may also lead to higher costs.
  • The form can be submitted without full completion. It is incorrect to believe that incomplete forms can still be processed. Failure to complete each required step may lead to delays in fulfilling orders.
  • Contacting Cigna Tel-Drug is unnecessary after submission. Many users think they can submit the fax form and wait without further communication. However, follow-up calls may be necessary to confirm receipt and clarify any issues with the order.

Understanding these misconceptions can help streamline the process and ensure that prescriptions are filled accurately and promptly.

Key takeaways

Using the Cigna Tel Drug Fax form correctly ensures smooth processing of your prescription order. Here are some key takeaways to keep in mind:

  • Complete All Steps: Fill out Steps 1 through 4 fully before completing Steps 5 and 6 as needed. Incomplete forms may cause delays in processing your order.
  • Clear and Accurate Information: Print all information clearly using black or blue ink. Ensure that the details you provide are accurate to prevent complications.
  • Payment Methods: Enclose your payment method and original prescriptions only. Remember that copies of prescriptions will not be accepted.
  • Avoid Staples: Do not staple any items to the form. This practice helps prevent issues during the processing of your prescription request.