If requesting more than 10 HCPCS codes please attach another form.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation.The Cigna name,
logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2019 Cigna
INT_19_75090_C 928896
Expedited – dened 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?
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 and relevant radiology notes.
All chemotherapy orders must indicate the number of cycles requested: Cycles
HCPCS codes Drug name
(if applicable)
(if applicable)
Frequency Duration