Transcription of Anti-TNF Coverage Determination Form Cigna …
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Anti-TNF Coverage Determination Form Cigna …
Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) Customer ID:Customer DOB:Customer Address:Phone (Home):Phone (Cell):NPI Number:Provider Name:Provider Address:Drug Name:Dosage:Frequency:Quantity:Refills: New Medication ContinuationProvide Start Date---------> Ankylosing Spondylitis Plaque Psoriasis Crohn's Disease (Fistulizing, Ulcerative Colitis) Psoriatic Arthritis Hidradenitis Suppurativa Rheumatoid Arthritis Juvenile Rheumatoid Arthritis Uveitis Other _____SELECT DIAGNOSISMEMBER INFORMATION REQUIRED (Please Write Legibly)Customer Name:PROVIDER INFORMATION REQUIRED (Please Write Legibly)License Number:DEA Number: Do Not Substitute-Dispense As WrittenProvider Specialty:DRUG & PRESCRIPTION INFORMATION REQUIRED (Please Write Legibly)Provider Phone:Please check whether this is a new medication or therapy continuationProvider Fax:Office Contact Name:If you have checked "Continuation", AntiTNF_FormINT_17_59000 09152017 Page 1 of 3 Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) DosageFrequencyQuantity6-MercaptopurineA zathioprineCelebrexCorticosteroidsCyclop hosphamideEnbrel (pri)
Anti-TNF Coverage Determination (FOR PROVIDER USE ONLY) List NSAIDS tried: List weight in Kg: For Plaque Psoriasis
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