Please attach all required documentation: recent clinical notes, copy of the prescription or physician order,
relevant diagnostic labs.
HCPCS codes Equipment name
(if applicable)
Quantity Limit
every 30 days
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.
Expedited – dened as may seriously jeopardize the life or health of the Customer or the Customer’s
ability to regain maximum function if not provided with 72 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 items?
DME Provider
Other. Please specify:
Please select place of service by checking only one of the boxes:
Other. Please specify:
Diagnosis codes: Diagnosis:
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.
INT_20_83310_C 936998 11/19 © 2019 Cigna
Q1: For non-preferred glucose monitor or test strip – Has the patient tried preferred glucose monitor or test strip?
If no, please indicate the need for non-preferred glucose monitor or test strip. Preferred meters are Abbott Meters
and Ascencia Meters.
Q2: For high utilization of test strips – Has the patient had an in-person visit with the provider within the past 6
months and provider certied the need for test strips greater than 200 test strips every 30 days that the plan allows?
Q3: For Talking glucose monitor – Does the patient have severe visual or manual dexterity impairment requiring use
of this special monitoring system?