Dexilant 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
□
Continuation
Provide Start Date--------->
MEMBER INFORMATION REQUIRED
(Please Write Legibly)
Customer Name:
PROVIDER INFORMATION REQUIRED
(Please Write Legibly)
License Number: DEA Number:
□
Do Not Substitute-Dispense As Written
Provider Specialty:
DRUG & PRESCRIPTION INFORMATION REQUIRED
(Please Write Legibly)
Provider Phone:
Please check whether this is a new medication or therapy continuation
Provider Fax:
Office Contact Name:
DIAGNOSIS INFORMATION REQUIRED
(Please Write Legibly)
List Diagnosis/ICD-10 Code(s):
If you have checked "Continuation",
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INT_20_80754 09272019
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Dexilant Coverage Determination
(FOR PROVIDER USE ONLY)
Dosage Frequency Quantity
Other Questions:
Is this request for an inpatient that is awaiting discharge?
□
YES
□
NO
If the customer is unable to meet the criteria required for the requested medication, please provide a clinical explanation as to why an exception should be made:
Date:
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. Enrollment
in Cigna-HealthSpring depends on contract renewal.
ATTENTION: PLAN REQUIRES A TRIAL OF AT LEAST 2 FORMULARY ALTERNATIVES; FAILURE TO
PROVIDE CLINICAL DOCUMENTATION SUPPORTING RATIONALE MAY RESULT IN THIS REQUEST
BEING DENIED, OR AN ADDITIONAL OUTREACH TO OBTAIN MISSING CLINICAL INFORMATION.
End DateStart Date
Other:
Provider Signature:
Request for expedited review [24 hours]. By checking this box, I certify that applying the 72 hour
standard review time frame may seriously jeopardize the life or health of the Customer or the Customer's ability to regain maximum function
Drug Name
CLINICAL INFORMATION REQUIRED
(Please Write Legibly)
Treatment Outcome/Rationale for Non Use
SELECT ALL FORMULARY AGENTS THAT THE CUSTOMER HAS TRIED/FAILED; PLEASE INCLUDE THE DOSAGE, FREQUENCY, QUANTITY,
DURATION OF THERAPY (START AND END DATES), AND OUTCOME/RATIONALE FOR NON USE :
Lansoprazole *alternative may not
apply to all plans
Omeprazole
Esomeprazole * alternative may
not apply to all plans
Pantoprazole
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INT_20_80754 09272019
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