PROVIDER INFORMATION PATIENT INFORMATION

Phone: (800)558-9363 - Medication Coverage Determination Form -
Fax: (855)840-1676 - Botox (botulinum toxin type A) -
P.O. Box 42005
Phoenix, AZ 85080-2005 Please Note: This form is intended for prescriber use to request a Formulary
Exception, Prior Authorization or Step Therapy Exception for Cigna Medicare
Services plan members. Failure to complete this form in its entirety may result in
an adverse determination for insufficient information.

PROVIDER INFORMATION PATIENT INFORMATION

* Provider Name: * DEA or TIN: **Due to privacy regulations we will not be able to
Specialty: respond via fax with the outcome of our review unless all
asterisked (*) items on this form are completed**

Office Contact Person: * Patient Name:

Office Phone: * Cigna ID:

Office Fax: * Date Of Birth:

* Is your fax machine kept in a secure location? Yes No * Patient Street Address:
* May we fax our response to your office? Yes No City State

Office Street Address: Zip

City State Zip Patient Phone:

Medication requested:

Botox 100 unit vial

Dose and Quantity: Duration of therapy: J-Code:

In what location(s) of the body will Botox injections be given (please specify how many units are being injected into each muscle)?

Please indicate the condition Botox is being used to treat and answer additional questions as necessary.
Please include all applicable chart notes with this form.

Blepharospasm

Cervical dystonia, including spasmodic torticollis

Additional Is the patient’s condition causing persistent pain or Answer/Detail:
Question(s) interfering with the patient's ability to perform age-
related activities of daily living?

“Cigna,” “Cigna Medicare Services” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by
Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including
Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company (CHLIC), and Cigna HealthCare of Arizona, Inc. (CHC-
AZ), and not by Cigna Corporation. Cigna Medicare Rx is a PDP plan with a Medicare contract. Enrollment in Cigna Medicare Rx depends on
contract renewal. Cigna Medicare Select Plus Rx (HMO) plans are offered by CHC-AZ under a contract with Medicare. Enrollment in Cigna
Medicare Select Plus Rx depends on contract renewal.

Cigna Medicare Services Coverage Determination Form – Botox – Page 1 of 4

Focal hand dystonia (e.g., writer's cramp)

Additional Is the patient’s condition causing persistent pain or Answer/Detail:
Question(s) interfering with the patient's ability to perform age-
related activities of daily living?

Adductor spasmodic dysphonia/laryngeal dystonia

Additional Is the patient’s condition interfering with their ability to Answer/Detail:
Question(s) communicate effectively?

Jaw-closing oromandibular dystonia

Additional Is the patient’s condition causing persistent pain, Answer/Detail:
Question(s) interference with nutritional intake (e.g., masticatory
dysfunction that results in weight loss or malnutrition), or
significant speech impairment/interference with the
ability to communicate effectively?

Meige's syndrome/cranial dystonia (i.e., blepharospasm with jaw-closing oromandibular cervical dystonia)

Additional Is the patient’s condition causing persistent pain, Answer/Detail:
Question(s) interference with nutritional intake (e.g., masticatory
dysfunction that results in weight loss or malnutrition), or
significant speech impairment/interference with the
ability to communicate effectively?

Spasticity due to cerebral palsy (including spastic equinus foot deformities)

Additional What is the specific location of the spasticity? Answer/Detail:
Question(s)

Spasticity due to cerebrovascular accident

Additional What is the specific location of the spasticity? Answer/Detail:
Question(s)

Spasticity due to localized adductor muscle spasticity in multiple sclerosis

Additional What is the specific location of the spasticity? Answer/Detail:
Question(s)

Cigna Medicare Services Coverage Determination Form – Botox – Page 2 of 4

Spasticity due to spinal cord injury

Additional What is the specific location of the spasticity? Answer/Detail:
Question(s)

Spasticity due to traumatic brain injury

Additional What is the specific location of the spasticity? Answer/Detail:
Question(s)

Hemifacial spasms/Seventh cranial nerve palsy

Additional Is the patient’s condition causing persistent pain or Answer/Detail:
Question(s) vision impairment?

Horizontal strabismus in an adult

Additional How many prism diopters does the patient have? Answer/Detail:
Question(s) Answer/Detail:

Does the patient have diplopia, impaired depth
perception, impaired peripheral vision, or impaired
ability to maintain fusion?

Vertical strabismus in an adult

Additional Does the patient have diplopia, impaired depth Answer/Detail:
Question(s) perception, impaired peripheral vision, or impaired
ability to maintain fusion?

Persistent sixth nerve palsy in an adult

Additional When was the patient diagnosed with this condition? Answer/Detail:
Question(s)

Cigna Medicare Services Coverage Determination Form – Botox – Page 3 of 4

Does the patient have diplopia, impaired depth Answer/Detail:
perception, impaired peripheral vision, or impaired
ability to maintain fusion?

Strabismus disorder in a child

Additional Is Botox being used to achieve normal binocular motor Answer/Detail:
Question(s) alignment?

Primary esophogeal achalasia

Additional Is the patient considered a poor surgical risk (e.g., Answer/Detail:
Question(s) patients with comorbidities such as elderly patients with
decreased life expectancy)?

Does the patient have a history of perforation caused by Answer/Detail:
previous pneumatic dilatation?

Chronic anal fissure

Additional Has the patient failed conventional non-surgical Answer/Detail:
Question(s) treatment (e.g., nitrate preparations, sitz baths, stool
softeners, bulk agents, diet modifications)

Primary or secondary axillary or palmar hyperhidrosis OR gustatory sweating (Frey's syndrome)

Additional Is the condition refractory to conventional medical Answer/Detail:
Question(s) treatment, including an attempt at both topical and
pharmacotherapy (unless clinically contraindicated)?

Is the condition significantly interfering with the patient's Answer/Detail:
ability to perform age-appropriate activities of daily
living?

The condition is causing persistent or chronic cutaneous Answer/Detail:
conditions such as skin maceration, dermatitis, fungal
infections and secondary microbial conditions?

Voiding dysfunction associated with intracranial lesions or cerebrovascular accident-induced voiding
difficulty

Voiding dysfunction associated with detrusor sphincter dyssynergia due to spinal cord injury

Other (Please specify diagnosis and any additional applicable information)

Please fax completed form to (855)840-1676. Phone requests may be submitted by calling (800)558-9363.

Expedited/Urgent By checking this box and signing below, I certify that applying the standard 72 hour review time frame may

seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.

Signature:

V112013

Cigna Medicare Services Coverage Determination Form – Botox – Page 4 of 4