Cigna pharmacy prior authorization form

Key terms. Benefit summary. Prescription drug benefits What is on this page. Back to top top. Limitations Each prescription drug order or refill will be limited as follows: Up to a consecutive thirty 30 -day supply at a Participating Retail Pharmacy, unless limited by the drug manufacturer's packaging; Up to a consecutive ninety 90 -day supply at a Participating Retail or Cigna Home Delivery Pharmacy, unless limited by the drug manufacturer's packaging, or To a dosage limit as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee.

If two or more prescriptions or refills are dispensed at the same time a Copayment must be paid for each prescription order or refill. When a treatment regimen contains more than one type of drug and the drugs are packaged together for the convenience of the covered person, a co-insurance will apply to each type of drug.

For maintenance medications, as determined by Cigna, and generally drugs taken on a regular basis to treat ongoing conditions, Cigna will provide coverage for two fills for 30 days at a retail pharmacy. For additional refills, these maintenance medications will only be covered when members order a day supply through a Participating Retail Cigna Home Delivery Pharmacy. Cigna will also apply, step therapy prior authorization program rules for certain medications as identified by Cigna.

Individuals affected by these rules will be contacted directly by Cigna. When both a generic and a name brand drug are available, and the participant receives the name brand drug, the member is responsible for the applicable copay and the difference in cost between the name brand drug and the generic drug.

Exclusions No payment will be made for the following expenses: Drugs or medications available over the counter for which state or federal laws do not require a prescription or medication that is equivalent in strength, regardless of form to an over the counter drug or medication. Injectable drugs or medicines, including injectable infertility drugs other than injectables included on the Formulary, used to treat diabetes, acute migraine headaches, anaphylactic reactions, vitamin deficiencies and injectables used for anticoagulation.

However, upon prior authorization by Cigna, injectable drugs may be covered subject to the required Copayment; Any drugs that are labeled as experimental or investigational.

Medical literature means scientific studies published in a peer-reviewed national professional medical journal. Prescription and nonprescription supplies such as ostomy supplies , devices, and appliances other than syringes used in conjunction with injectable medications and glucose test strips. Prescription drugs or medications used for treatment of sexual dysfunction, including, but not limited to erectile dysfunction, delayed ejaculation, anorgasmy and decreased libido.

Prescription vitamins other than prenatal vitamins , dietary supplements and fluoride products, except for formulas prescribed by a Participating Physician as necessary for the treatment of phenylketonuria or similar inheritable conditions that may cause or result in mental or physical disability. Prescription drugs used for cosmetic purposes such as: drugs used to reduce wrinkles, drugs to promote hair growth, drugs used to control perspiration, and fade cream products.

Diet pills, or appetite suppressants anorectics. Prescription smoking cessation products above the dosage limit as determined by Cigna HealthCare Pharmacy, and Therapeutics Committee. Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis, with the exception of malaria prophylactic drugs.

Malaria prophylactic drugs are covered. Replacement of Prescription Drugs due to loss or theft except as part of disaster relief efforts. Medications used to enhance athletic performance. Medications which are to be taken by or administered to a participant while the participant is a patient in a licensed Hospital, skilled nursing facility, rest home or similar institution with a facility dispensing pharmaceuticals on it premises.

Prescriptions more than one year from the original date of issue. A drug class in which at least one of the drugs is available over the counter and the drugs in the class are deemed to be therapeutically equivalent as determined by the Pharmacy and Therapeutics Committee such as antihistamines. Norplant, and other implantable contraceptive products. General limitations Medical benefits No payment will be made for expenses incurred for you or any one of your Family Members: For or in connection with an Injury arising out of, or in the course of, any employment for wage or profit.

For or in connection with a Sickness which is covered under any workers' compensation or similar law. For charges made by a Hospital owned or operated by or which provides care or performs services for the United States Government, if such charges are directly related to a military-service-connected Sickness or Injury. To the extent that payment is unlawful where the person resides when the expenses are incurred: For charges which the person is not legally required to pay.

For charges for unnecessary care, treatment, or surgery. For or in connection with Custodial Services, education, or training. Depending on a patient's plan, you may be required to request a prior authorization or precertification for any number of prescriptions or services. To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA, fax, and phone coverage reviews also called prior authorizations to Electronic Prior Authorizations ePAs.

If you are unable to use electronic prior authorization, you can call us at 1 to submit a prior authorization request. Back to Coverage and Claims. All rights reserved. All insurance policies and group benefit plans contain exclusions and limitations.

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