MEDICARE ADVANTAGE DRUGS/BIOLOGICS PART B
If requesting more than 10 HCPCS codes please attach another form.
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Expedited – dened as danger to a patient’s health if not provided within 24 hours
Patient name: Date of birth:
Name of requesting provider: ID number:
Contact person: Date of service:
NPI number: Phone number: Fax number:
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
completed form to 1-877-730-3858. Questions? Call 1-888-454-0013. Note: In an effort to process your request in
a timely manner, please submit all pertinent clinical information.
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/out-of-network provider/facility, please explain why:
New authorization request Extension of existing authorization. For extension of existing
authorization, please submit Authorization Number:
Who will supply the medication?
Pharmacy not located within
the servicing facility
Please select place of service by checking only one of the boxes:
Other. Please specify:
Diagnosis codes: Diagnosis:
Please attach all required documentation: recent clinical notes, copy of the prescription or physician order,
relevant diagnostic labs and relevant radiology notes.
All chemotherapy orders must indicate the number of cycles requested: Cycles
HCPCS codes Drug name