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and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2019 Cigna
INT_19_81858 926102
Expedited – dened as danger to a patient’s health if not provided within 24 hours
Patient name: Patient date of birth:
Name of requesting provider: ID number:
Contact person: Date of service:
NPI number: Phone number: Fax number:
If referring to a (servicing) provider, the below stated information must be submitted:
Name of servicing provider: Phone number:
Contact person: Fax number:
Address: NPI number:
Please check if servicing provider is non-contracted
If servicing provider is non-contracted/out-of-network provider/facility, please explain why:
Who will supply the medication?
Provider oce
Outpatient hospital/clinic
Pharmacy not located within
the servicing facility
Please select place of service by checking only one of the boxes:
Provider oce
Outpatient hospital/clinic
Other. Please specify:
Diagnosis codes: Diagnosis:
Please attach all required documentation: recent clinical notes, copy of the prescription or physician order,
relevant diagnostic labs.
HCPCS codes Drug name
(if applicable)
(if applicable)
Frequency Duration
Q1: Is this a new start or a continuation of therapy within the past 365 days?
Q2: Has the patient had an intolerance or an inadequate response to a Step 1 alternative (Zarxio or Nivestym)?
Q3: If patient is unable to try a Step 1 alternative (Zarxio or Nivestym), please provide the reason(s) why an
exception should be made to the step therapy requirement:
This precertication form applies to all Cigna Medicare markets except Arizona and Leon health plans. This
precertication form does not apply to Medicaid only and Medicare/Medicaid Plan (MMP) plans. Please fax to:
1-877-730-3858 | Phone: 1-888-454-0013
Note: In an eort to process your request in a timely manner, please submit all pertinent clinical information.