MEDICARE ADVANTAGE DRUGS/BIOLOGICS PART B
PRECERTIFICATION FORM
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna
Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
© 2020 Cigna
INT_20_91394_C
924585 09/2020
Expedited – defined 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:
Address:
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 office
Outpatient hospital/clinic
Pharmacy not located within
the servicing facility
Please select place of service by checking only one of the boxes:
Provider office
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)
Dose
(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 Monovisc, Orthovisc,
Synvisc, or Synvisc One*?
Q3: If patient is unable to try a Step 1 alternative Monovisc, Orthovisc, Synvisc, or Synvisc One*, please provide the
reason(s) why an exception should be made to the step therapy requirement:
This precertification form applies to all Cigna Medicare markets except Arizona and Leon health plans. This
precertification 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 effort to process your request in a timely manner, please submit all pertinent clinical information.
*Cigna requires precertification for Step 1 alternative - Monovisc, Orthovisc, Synvisc, or Synvisc One
PART B STEP THERAPY - DUROLANE, EUFLEXXA, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS,
SODIUM HYALURONATE 1%, SUPARTZ FX, SYNOJOYNT, TRILURON, TRIVISC, VISCO-3
