cigna healthspring prior authorization template

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you or your prescriber may request a coverage decision or exception for the prescribed medication. without prior authorization, the drug may not be covered. if no drug-specific form is available, please use the general coverage determination form. all cigna products and services are provided exclusively by or through operating subsidiaries of cigna corporation, including cigna health and life insurance company, cigna healthcare of south carolina, inc., cigna healthcare of north carolina, inc., cigna healthcare of georgia, inc., cigna healthcare of arizona, inc., cigna healthcare of st. louis, inc., healthspring life & health insurance company, inc., healthspring of florida, inc., bravo health mid-atlantic, inc., and bravo health pennsylvania, inc. the cigna name, logos, and other cigna marks are owned by cigna intellectual property, inc. cigna-healthspring is contracted with medicare for pdp plans, hmo and ppo plans in select states, and with select state medicaid programs. our company and agents are not connected with or endorsed by the u.s. government or the federal medicare program.

this is a solicitation for insurance. premium and benefits vary by plan selected. medicare supplement policies are underwritten by cigna health and life insurance company, american retirement life insurance company or loyal american life insurance company. the following medicare supplement plans are available to persons eligible for medicare due to disability: plan a in connecticut, maryland, oklahoma & texas; plans a, f & n in california; plans a & c in michigan; plans a & f in north carolina; and plan c in new jersey for individuals aged 50-64.  selecting these links will take you away from cigna medicare advantage and medicare part d prescription drug plan information. this is useful for forms that you want to view and/or print.

prior authorization request form–outpatient. please fax to: referring to ( servicing) provider information: if below fields are not answered, cigna- healthspring will automatically assign prior authorization. generic fax request form. providers: you must get prior authorization (pa) for services before service is provided. for a list of cigna- healthspring services requiring pa, visit if no drug-specific form is available, please use the general coverage determination form. ×. opioids: , cigna prior authorization form 2019, cigna prior authorization form 2019, cigna prior authorization phone number, cigna radiology prior authorization, cigna prior authorization number.

if you are unable to use electronic prior authorization, you can call us at 1 (800) 882-4462 to submit a prior authorization this form may be sent to us by mail or fax: address: cigna-healthspring pharmacy service center attn: part d coverage i request prior authorization for the drug my prescriber has prescribed.*. this form may be sent to us by mail or fax: i request prior authorization for the drug my prescriber has prescribed.* healthspring is contracted with medicare for pdp plans, hmo and ppo plans in , cigna-healthspring forms, cigna botox prior authorization form, cigna botox prior authorization form, evicore cigna prior authorization, cigna healthspring prior authorization form dme

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