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Fill in Your Cigna And Remicade Template

The Cigna and Remicade form is a crucial document used to request prior authorization for the medication Remicade (infliximab). This form must be completed accurately to avoid delays in processing or potential denials due to insufficient information. Understanding its components is essential for healthcare providers seeking timely access to this important treatment for various autoimmune conditions.

Table of Contents

The Cigna and Remicade form serves as a crucial tool for healthcare providers seeking prior authorization for the administration of Remicade (infliximab), a medication used to treat various autoimmune conditions. This form requires detailed information about both the provider and the patient, ensuring that all necessary data is captured for a smooth approval process. Essential sections include the provider's name, contact information, and the patient's demographics, such as their Cigna ID and date of birth. The form also prompts the provider to specify the medication requested, dosage, frequency of administration, and the diagnosis related to its use. Additionally, healthcare professionals must indicate the patient's treatment history, including any prior use of Remicade and responses to other therapies. To facilitate a timely review, it’s critical to complete the form in its entirety; incomplete submissions may lead to delays or unfavorable decisions. The form also outlines the method of measuring disease progression and requires documentation of any previous beneficial responses to Remicade therapy. With clear instructions and a dedicated contact for pharmacy services, this form aims to streamline the authorization process while safeguarding patient privacy and ensuring compliance with healthcare regulations.

Sample - Cigna And Remicade Form

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

↓ Cigna And Remicade PDF

File Specs

Fact Name	Description
Provider Information	This section requires the provider's name, specialty, DEA or TIN, office contact person, and contact details.
Patient Information	Important details about the patient include their name, CIGNA ID, date of birth, and address.
Medication Requested	The form specifically requests authorization for Remicade (infliximab) and asks for dosage and quantity.
Diagnosis	Patients must indicate their diagnosis, which may include conditions like rheumatoid arthritis or Crohn’s disease.
Previous Treatment	Questions about past Remicade use and responses to other therapies are included to assess the patient’s history.
Measurement of Disease Progression	Providers must specify how they measured the patient’s disease progression prior to therapy.
Renewal of Authorization	If this is a request for continued therapy, the provider must document the patient's improvement since starting treatment.
Response Time	Standard response time for coverage requests is 2-4 business days, with urgent requests needing a call to Pharmacy Services.

Cigna And Remicade - Usage Guidelines

Completing the Cigna and Remicade form requires careful attention to detail. Each section must be filled out completely to avoid delays in processing. After submitting the form, Cigna will review the information provided and respond within a standard timeframe. If the request is urgent, contacting Pharmacy Services directly can help expedite the process.

Begin with the Provider Information. Fill in the following details:

Provider Name

Specialty

DEA or TIN

Office Contact Person

Office Phone

Office Fax

Office Street Address

City, State, Zip

Next, move to the Patient Information section. Complete the required fields:

Patient Name

CIGNA ID

Date of Birth

Patient Street Address

City, State, Zip

Patient Phone

Indicate whether your fax machine is kept in a secure location and if you may fax the response to your office.

Specify the Medication Requested:

Remicade (infliximab) 100mg vial

Other (please specify)

Fill in the Dose and Quantity, Duration of Therapy, J-Code, and Frequency of Administration.

Indicate where the medication will be obtained:

CIGNA Tel-Drug

Retail pharmacy

Prescriber’s office stock

Home Health / Home Infusion vendor

Other (please specify)

Provide the Diagnosis Related to Use and specify the patient's current weight.

Answer whether the patient has been on Remicade in the past and if they had a beneficial clinical response.

For specific conditions, answer the relevant questions about previous treatments and responses:

Psoriatic or Reactive Arthritis

Rheumatoid Arthritis

Chronic Plaque Psoriasis

Crohn’s Disease

Fistulizing Crohn’s Disease

Inflammatory Bowel Disease Arthritis

Ankylosing Spondylitis

Ulcerative Colitis

Document any additional pertinent information that may support the request.

Finally, fax the completed form to (800)390-9745. Ensure you have all necessary information included to avoid delays.

Your Questions, Answered

What is the purpose of the Cigna and Remicade form?

The Cigna and Remicade form is designed to facilitate the prior authorization process for patients seeking coverage for Remicade (infliximab). This medication is used to treat various conditions such as rheumatoid arthritis, psoriatic arthritis, and Crohn's disease, among others. Completing the form accurately ensures that Cigna can review the request efficiently and determine eligibility for coverage based on medical necessity.

What information is required to complete the form?

The form requires detailed information about both the provider and the patient. Key sections include provider details, patient demographics, and specific treatment-related questions. Essential items include the patient's CIGNA ID, date of birth, current weight, and a thorough history of prior treatments. Incomplete forms may lead to delays or denials due to insufficient information.

How long does it take to receive a response after submitting the form?

Typically, Cigna's standard response time for prescription drug coverage requests is between 2 to 4 business days. If the request is urgent, it is advisable to contact Pharmacy Services directly to expedite the review process. This ensures that the patient's treatment is not delayed unnecessarily.

What should I do if my patient has been on Remicade in the past?

If the patient has previously received Remicade, it is crucial to indicate this on the form, including the previous dosage and any documented beneficial responses. This information can significantly impact the approval process, especially if the patient is requesting continued therapy. Providers should also document any changes in the patient’s condition since their last treatment.

Where can I find additional information regarding Cigna's coverage positions?

Additional information regarding Cigna's coverage positions for Remicade and other medications can be accessed online at Cigna's official website. Specifically, the coverage positions can be found at http://www.cigna.com/customer_care/healthcare_professional/coverage_positions. This resource provides valuable insights into what medications are covered and under what circumstances.

Common mistakes

Incomplete Information: Failing to fill out all required fields, especially those marked with an asterisk, can lead to delays. Each section must be thoroughly completed to ensure timely processing.

Incorrect Patient Details: Providing inaccurate patient information, such as the CIGNA ID or date of birth, can cause significant issues. Double-checking these details is essential.

Misunderstanding Medication Requests: Not specifying the correct dosage or failing to indicate whether the medication is a continuation of previous therapy can lead to misunderstandings. Be clear about the medication requested and its intended use.

Neglecting Previous Treatment History: Omitting information about the patient's past use of Remicade or other treatments can hinder the approval process. It’s important to detail any previous dosages and responses.

Forgetting Secure Fax Confirmation: Not confirming whether the fax machine is secure can lead to privacy violations. Ensure that this section is addressed to comply with regulations.

Inadequate Documentation of Disease Progression: Failing to provide adequate evidence of disease progression or response to previous therapies can result in denial. Include all relevant assessments and scores.

Ignoring Additional Information: Not including any pertinent information that may support the request can weaken the application. If there are any special circumstances or considerations, they should be noted.

Documents used along the form

When submitting the Cigna and Remicade form, there are several other documents that may be required or helpful in the process. Each of these forms serves a specific purpose and can aid in ensuring that the necessary information is provided for a smooth authorization process.

Prior Authorization Request Form: This form is often required to obtain approval from the insurance company before a medication can be dispensed. It collects essential information about the patient's condition and treatment plan.

Patient Medical History: A detailed medical history provides context about the patient’s past treatments and responses. This can help support the need for the requested medication.

Clinical Notes: Notes from healthcare providers detailing the patient’s diagnosis, treatment history, and current health status can be crucial. These notes can substantiate the medical necessity of the treatment.

Lab Results: Relevant laboratory test results, such as blood tests or imaging studies, can provide evidence of the patient's condition and the need for treatment with Remicade.

Medication History: A record of all medications the patient has tried in the past, including any adverse reactions, can support the case for using Remicade.

Insurance Information: This document includes details about the patient’s insurance coverage, which is necessary for processing the prior authorization request.

Patient Consent Form: This form may be required to ensure that the patient agrees to share their medical information with the insurance provider and other involved parties.

Appeal Form: If a prior authorization request is denied, an appeal form can be used to formally contest the decision, providing additional evidence or clarification.

Specialty Pharmacy Information: If the medication is to be obtained through a specialty pharmacy, this document may include details about the pharmacy and the process for ordering the medication.

Having these documents prepared and organized can facilitate the process of obtaining authorization for Remicade. Each piece of information contributes to a clearer understanding of the patient's needs and supports the request for coverage.

Similar forms

The Cigna and Remicade form is similar to the Prior Authorization Request form used by many insurance companies. Like the Cigna form, this document requires detailed patient information, including medical history and current medications. Both forms aim to ensure that the requested treatment is medically necessary and that the patient has exhausted other treatment options. The completion of these forms is crucial for timely approval of medications, reducing delays in patient care.

Another document akin to the Cigna and Remicade form is the Medication Prior Authorization form. This form is often required for high-cost medications or those not typically covered by insurance plans. Similar to the Cigna form, it collects information about the patient's diagnosis, previous treatments, and the rationale for using a specific medication. Both documents emphasize the importance of providing comprehensive information to avoid delays in processing and approval.

The Specialty Pharmacy Authorization form also shares similarities with the Cigna and Remicade form. This document is specifically designed for medications that require special handling or monitoring. Both forms request detailed patient and provider information and require justification for the use of specialty medications. They serve to streamline the approval process and ensure that patients receive the necessary medications in a timely manner.

The Durable Medical Equipment (DME) Authorization form is another comparable document. This form is used to obtain approval for medical equipment that may be costly or not routinely covered. Like the Cigna form, it requires specific details about the patient's condition and the medical necessity for the equipment. Both forms aim to facilitate access to essential medical resources while ensuring compliance with insurance policies.

The Outpatient Therapy Authorization form is similar in its purpose to the Cigna and Remicade form. It is used to request approval for outpatient therapies, such as physical or occupational therapy. Both forms require patient information and a detailed explanation of the therapy's necessity. They help ensure that patients receive appropriate care while adhering to insurance guidelines.

The Hospital Admission Authorization form is another document that aligns with the Cigna and Remicade form. This form is used to obtain pre-approval for hospital admissions, ensuring that the patient's stay is medically necessary. Both forms require comprehensive patient information and justification for the requested services. They help streamline the admission process and minimize potential issues with insurance coverage.

The Imaging Authorization form is similar in that it is used to request approval for imaging services, such as MRIs or CT scans. Like the Cigna form, it collects relevant patient information and requires a clear rationale for the imaging study. Both documents are designed to ensure that patients receive necessary diagnostic services while adhering to insurance protocols.

The Clinical Trial Authorization form is another document that shares similarities with the Cigna and Remicade form. This form is used to request approval for patient participation in clinical trials. Both forms require extensive patient information and justification for the treatment being sought. They aim to ensure that patients have access to innovative therapies while complying with insurance requirements.

Lastly, the Prescription Drug Coverage Determination form is comparable to the Cigna and Remicade form. This document is used to appeal a denial of coverage for a specific medication. Like the Cigna form, it requires detailed patient information and a clear explanation of why the medication is necessary. Both forms are crucial for advocating for patient access to essential medications while navigating insurance policies.

Dos and Don'ts

When filling out the Cigna and Remicade form, careful attention to detail is crucial. Here are five important actions to take and avoid:

Do complete all required fields: Ensure that every asterisked (*) item is filled out to prevent delays.

Do provide accurate patient information: Double-check the patient’s name, CIGNA ID, and date of birth for accuracy.

Do specify the medication details: Clearly indicate the requested medication, dosage, and duration of therapy.

Do ensure secure faxing: Confirm that your fax machine is in a secure location before sending sensitive information.

Do follow up if necessary: If you do not receive a response within the standard time frame, contact Pharmacy Services.

Don't leave sections blank: Incomplete forms may lead to adverse determinations.

Don't use abbreviations: Avoid shorthand that may confuse the reviewer; clarity is key.

Don't forget to check for updates: Review the latest guidelines or changes in the form process before submission.

Don't submit without a cover sheet: Including a cover sheet can help ensure that your form is directed appropriately.

Don't ignore the urgency: If the request is urgent, make sure to call Pharmacy Services to expedite the process.

Misconceptions

Misconceptions about the Cigna and Remicade form can lead to confusion and delays in treatment. Here are eight common misconceptions clarified:

All fields are optional. Many believe that incomplete forms are acceptable. In reality, missing information can result in processing delays or adverse determinations.

Fax responses are always sent back to the provider. Due to privacy regulations, Cigna cannot fax outcomes unless all required fields are completed.

Only one medication can be requested at a time. Multiple medications can be requested, but each must be clearly documented on the form.

Previous treatment history is irrelevant. Cigna requires information on past treatments to assess the patient's eligibility for Remicade.

Patients do not need to provide their weight. Current weight is essential for dosage and treatment evaluation, so it must be included.

Renewals do not need additional documentation. Even for renewal requests, providers must document any improvements since starting therapy.

Responses are immediate. Standard response times for coverage requests are 2-4 business days, and urgent requests should be communicated directly.

The form can be submitted without a diagnosis. A specific diagnosis related to the use of Remicade must be provided for approval.

Understanding these points can help ensure a smoother process when submitting the Cigna and Remicade form.

Key takeaways

When filling out the Cigna and Remicade form, consider the following key takeaways:

Complete all sections: Ensure that every required field is filled out. Incomplete forms may lead to delays or denials.

Secure faxing: Confirm that your fax machine is in a secure location to protect patient privacy.

Diagnosis specification: Clearly specify the diagnosis related to the use of Remicade. This information is crucial for approval.

Previous treatment history: Provide details on any prior use of Remicade, including dosage and effectiveness.

Current weight: Include the patient's current weight, as it may impact dosing and treatment decisions.

Evidence of prior therapy: Document any previous therapies and the patient’s response to them, especially if they failed or had intolerances.

Measurement methods: Indicate the methods used to assess the patient's disease progression before starting Remicade.

Renewal requests: If seeking a renewal, provide evidence of improvement since beginning therapy.

Timely submission: Fax the completed form promptly to avoid delays. Expect a response within 2-4 business days.

Following these guidelines will help ensure a smoother process when submitting the Cigna and Remicade form.