Homepage Fill in Your Cigna Tel Drug Fax Template
Table of Contents

The Cigna Tel Drug Fax form serves as an essential tool for individuals seeking to order medications through Cigna Tel-Drug. This form is designed to streamline the prescription ordering process, ensuring that all necessary information is collected efficiently. Users must complete several steps, including providing insurance cardholder details, selecting shipping methods, and specifying payment options. It is crucial to fill out the form clearly, using black or blue ink, to avoid delays in processing. Additionally, the form emphasizes the importance of enclosing original prescriptions, as copies will not be accepted. Steps also include a section for disclosing allergies and health conditions, which is vital for the safety of the patient. Furthermore, the form allows for the ordering of both new prescriptions and refills, with clear instructions on how to proceed with each. By adhering to the outlined steps and providing accurate information, users can facilitate a smoother and more efficient medication ordering experience.

Sample - Cigna Tel Drug Fax Form

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.

 

.

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

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* 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.

File Specs

Fact Name Description
Form Purpose This form is used to order prescriptions through Cigna Tel-Drug.
Information Accuracy By submitting the form, you confirm that all provided information is correct.
Shipping Options Standard shipping is the default unless another method is selected.
Payment Requirements Payment must be included with the order; copies of prescriptions are not accepted.
Allergy Disclosure Patients must disclose allergies and health conditions with each order.
Refill Process Refills can be ordered via phone or online, not included on this form.
Brand vs. Generic Patients can request brand-name medications; this may incur higher costs.
Governing Law For Pennsylvania residents, the governing law includes the Pharmacy Act.

Cigna Tel Drug Fax - Usage Guidelines

Filling out the Cigna Tel Drug Fax form is a straightforward process that ensures your prescription order is processed efficiently. To avoid delays, it's essential to provide accurate and complete information. Follow these steps carefully to ensure your order is submitted correctly.

  1. Step 1: Insurance Cardholder Information
    • Enter the Cardholder ID number.
    • Provide the full name of the cardholder for this order.
    • Fill in the temporary shipping address, including street address, city, state, and zip code.
    • Include the cardholder's home and alternate phone numbers.
    • List the cardholder's employer and email address.
  2. Step 2: Shipping
    • Select your preferred shipping method by checking the appropriate box.
    • Be aware that if this section is left blank, standard shipping will be used.
  3. Step 3: Payment
    • Choose a payment method by checking the corresponding box.
    • If paying by credit card, fill in the required credit card information, including the card type, number, expiration date, and name on the card.
    • Ensure that you include any applicable copayments or special shipping costs.
  4. Step 4: Allergies & Health Conditions
    • Provide the patient's full name and birth date.
    • Check any known allergies or indicate if there are none.
    • List any major health conditions the patient may have.
  5. Step 5: Refill Prescriptions
    • For refills, provide the patient’s full name, birth date, and CIGNA Tel-Drug Rx number.
    • List the medication names and strengths for refills you wish to order.
  6. Step 6: New Prescriptions
    • Fill in the patient's full name and birth date.
    • Indicate whether to fill the prescription now or not.
    • Provide the medication name and strength, along with the prescriber’s full name and phone number.

Once you have completed the form, ensure that all sections are filled out clearly and accurately. Avoid staples and remember to include the original prescription along with your payment method. This will help facilitate a smooth processing of your order.

Your Questions, Answered

What is the Cigna Tel Drug Fax form used for?

The Cigna Tel Drug Fax form is utilized to order prescriptions through Cigna Tel-Drug. It allows patients to submit their prescription orders, specify shipping preferences, and provide necessary insurance and payment information. Proper completion of the form ensures efficient processing of medication orders.

How should I fill out the Cigna Tel Drug Fax form?

To complete the form, print all information clearly using black or blue ink. Follow the steps outlined in the form: provide insurance cardholder information, specify shipping preferences, include payment details, and disclose any allergies or health conditions. Ensure all required sections are filled out to avoid delays in processing.

What happens if I submit an incomplete form?

Submitting an incomplete form may result in delays in processing your order. It is essential to ensure that all required information is provided, particularly in the insurance, shipping, and payment sections. Double-check your entries before submitting to facilitate a smooth order experience.

Can I submit copies of my prescriptions with the form?

No, only original prescriptions are accepted with the Cigna Tel Drug Fax form. Copies of prescriptions will not be processed. It is crucial to enclose the original prescription(s) to ensure your order is filled correctly.

What payment methods are accepted?

The form allows for several payment methods, including checks, money orders, and credit cards. If you choose to pay by credit card, you must provide complete credit card information, including the card type, number, expiration date, and name on the card. Ensure that your payment information is accurate to avoid shipment delays.

How are shipping costs determined?

Shipping costs depend on the selected shipping method. Standard shipping is free, while expedited options, such as USPS Priority Mail and Federal Express, incur additional charges. The form outlines the costs associated with each shipping method, and it is important to select the appropriate option based on your needs.

What should I do if I have allergies or health conditions?

When filling out the form, it is necessary to complete the allergies and health conditions section each time you order medication. This information helps ensure that the prescribed medications are safe and appropriate for your health profile. If you have no known allergies, indicate this on the form.

How can I order refills for my prescriptions?

Refills can be ordered by calling the automated system at 1.800.TEL.DRUG (835.3784) or by visiting the Cigna website at mycigna.com. It is important not to include refills on the fax form if you plan to order them through these alternative methods. Keep your Cigna Tel-Drug Rx number handy for quick reference.

Common mistakes

  1. Incomplete Information: Many individuals forget to fill out all required fields. Each section of the form is crucial for processing the order smoothly. Missing information can lead to delays in receiving medications.

  2. Illegible Writing: Using unclear handwriting can create confusion. It is essential to print all information clearly using black or blue ink to ensure that all details are accurately captured.

  3. Incorrect Payment Method: Some people overlook providing complete payment information. This can prevent the shipment of the order, as the form requires specific details about payment methods to process the transaction.

  4. Not Following Shipping Instructions: Failing to select a shipping method can default the order to standard shipping. Individuals should ensure they check the appropriate box to avoid unnecessary delays.

  5. Neglecting Allergy Information: Omitting allergy details can pose serious health risks. Every time a medication is ordered, it is vital to complete the allergies and health conditions section to ensure safety.

  6. Submitting Copies of Prescriptions: Some individuals mistakenly send copies instead of original prescriptions. The form explicitly states that only original prescriptions will be accepted, and this oversight can lead to order rejection.

Documents used along the form

The Cigna Tel Drug Fax form is an essential document for ordering medications through Cigna. However, it is often accompanied by several other forms and documents that facilitate the prescription process and ensure that all necessary information is collected. Here are some commonly used forms and documents that may accompany the Cigna Tel Drug Fax form:

  • Insurance Verification Form: This document is used to confirm the patient's insurance coverage and benefits. It typically requires details such as the patient's policy number and group number, ensuring that the prescribed medications are covered under the patient's plan.
  • Patient Consent Form: This form obtains the patient's consent for the release of their medical information to Cigna. It is crucial for complying with privacy laws and ensures that the pharmacy can communicate with healthcare providers on behalf of the patient.
  • Prior Authorization Request Form: In some cases, specific medications may require prior approval from the insurance provider. This form is used to request authorization for coverage, detailing the medical necessity of the prescribed medication.
  • Medication History Form: This document collects information about the patient's previous medications, including any allergies or adverse reactions. It helps pharmacists ensure safe and effective medication management.
  • Refill Authorization Form: When patients need to refill their prescriptions, this form is used to request authorization for additional medication. It ensures that refills are processed promptly and accurately.
  • Shipping Information Form: This form provides specific details about where the medications should be shipped. It includes the recipient's address and any special instructions for delivery, ensuring that the medications reach the correct location without delay.

These forms and documents play a vital role in the medication ordering process, ensuring that patients receive their prescriptions efficiently and safely. Understanding their purpose can help streamline the experience for both patients and healthcare providers.

Similar forms

The Cigna Tel Drug Fax form shares similarities with the Prescription Drug Order Form commonly used in pharmacies. Both documents require clear identification of the patient and the prescriber, ensuring that the correct medication is dispensed. They include sections for insurance information and payment methods, which streamline the billing process. Additionally, both forms emphasize the importance of accurate and complete information to avoid delays in processing prescriptions.

Another comparable document is the Medication Refill Request Form. Like the Cigna form, this document allows patients to request refills of their existing prescriptions. It typically requires the patient's details, medication name, and the pharmacy's information. Both forms prioritize efficiency, aiming to ensure that patients receive their medications without unnecessary delays. Furthermore, both forms usually have a section for allergies and health conditions, helping pharmacists to avoid potential adverse reactions.

The New Patient Registration Form also bears similarities to the Cigna Tel Drug Fax form. This document collects essential information about a new patient, including personal details and insurance information. Both forms are designed to gather comprehensive data to facilitate the medication dispensing process. Additionally, both emphasize the need for accurate information to prevent complications in treatment and billing.

The Prior Authorization Request Form is another document that aligns with the Cigna Tel Drug Fax form. This form is often used to obtain approval from insurance companies before certain medications can be dispensed. Both documents require detailed patient and medication information, and they are crucial for ensuring that the prescribed treatment is covered by insurance. The emphasis on thoroughness in both forms helps avoid delays in medication access.

Similar to the Cigna form is the Patient Medication History Form, which collects a patient's previous medication usage and allergies. This document is vital for pharmacists to ensure safe prescribing and dispensing practices. Both forms require a complete understanding of the patient's health background, which helps in making informed decisions about current medications. They both also highlight the importance of clear communication between patients and healthcare providers.

The Insurance Claim Form is yet another document that parallels the Cigna Tel Drug Fax form. This form is used to submit claims to insurance companies for reimbursement of medication costs. Like the Cigna form, it requires detailed patient and insurance information, ensuring that claims are processed smoothly. Both forms are structured to facilitate quick and accurate processing, minimizing the potential for claim denials.

The Medication Administration Record (MAR) is another relevant document. This form is used by healthcare providers to document the administration of medications to patients. Similar to the Cigna form, the MAR requires precise patient identification and medication details. Both documents are critical in maintaining accurate records of medication usage, which is essential for patient safety and effective treatment outcomes.

Lastly, the Pharmacy Transfer Form shares characteristics with the Cigna Tel Drug Fax form. This document is used when a patient wishes to transfer their prescriptions from one pharmacy to another. Both forms require patient identification and medication details, ensuring that the transfer process is seamless. They both aim to maintain continuity of care by facilitating the transition of medications without interruption.

Dos and Don'ts

When filling out the Cigna Tel Drug Fax form, attention to detail is crucial to ensure a smooth process. Here are some key dos and don'ts to keep in mind:

  • Do print all information clearly using black or blue ink.
  • Do complete Steps 1 through 4 fully before moving to Steps 5 and 6.
  • Do include payment method and original prescriptions only; copies will not be accepted.
  • Do check the box for your preferred shipping method to avoid delays.
  • Don't forget to provide complete payment information to prevent shipment issues.
  • Don't staple any items to the form, as this can cause processing delays.
  • Don't include refills on this form if you plan to order them by phone or online.

Misconceptions

Misconceptions about the Cigna Tel Drug Fax form can lead to confusion and delays in processing. Here are nine common misunderstandings:

  1. Only new prescriptions can be submitted. Many believe that the form is exclusively for new prescriptions. However, it can also be used for refills, as long as they are properly indicated.
  2. Incomplete forms will still be processed. Some think that minor omissions won't matter. In reality, incomplete information can significantly delay processing and shipment.
  3. Copies of prescriptions are acceptable. It is a common belief that submitting a copy of a prescription will suffice. The form explicitly states that only original prescriptions will be accepted.
  4. Payment information is optional. Many assume that providing payment details is not crucial. In fact, failing to include complete payment information may prevent the shipment of the order.
  5. Shipping costs are fixed. Some people think that shipping fees are constant. In truth, these costs can vary based on weight, shipping method, and carrier policies.
  6. Allergies and health conditions can be skipped. It is a misconception that this section is not important. Every time a medication is ordered, this section must be completed to ensure safety.
  7. Special shipping affects order processing time. Some believe that choosing special shipping speeds up order processing. However, it only expedites delivery, not processing time.
  8. Any shipping method can be chosen without consequences. Many think that they can select any shipping option without regard for cost. It is essential to note that the customer is responsible for any special shipping costs incurred.
  9. Generic medications will always be the same. Some expect generic medications to look identical to their brand-name counterparts. However, manufacturers may change, resulting in variations in appearance.

Understanding these misconceptions can help ensure a smoother experience when using the Cigna Tel Drug Fax form.

Key takeaways

When using the Cigna Tel Drug Fax form, it is essential to follow specific guidelines to ensure a smooth process. Here are key takeaways to keep in mind:

  • Print Clearly: Use black or blue ink and print all information clearly to avoid processing delays.
  • Complete All Steps: Make sure to fill out Steps 1 through 4 completely before moving on to Steps 5 and/or 6.
  • Original Prescriptions Only: Enclose original prescriptions. Copies will not be accepted.
  • No Staples: Do not staple any documents to the form to prevent processing issues.
  • Shipping Information: If the shipping section is left blank, standard shipping will automatically be used.
  • Payment Details: Include complete payment information to avoid delays in processing your order.
  • Allergies Section: Always complete the allergies and health conditions section for every order.
  • Refill Orders: For refills, use the automated system or visit the website instead of including them on this form.
  • Generic Substitutions: Pharmacists may substitute generics unless you specify "Brand Only," which may result in higher costs.
  • Contact Information: Keep the contact details up to date for any necessary follow-up regarding your order.

By adhering to these guidelines, you can help ensure that your experience with the Cigna Tel Drug Fax form is efficient and effective.