Homepage Fill Out Your Cigna Tel Drug Fax Form
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The Cigna Tel Drug Fax form is an essential tool for individuals seeking medications through Cigna’s Tel-Drug service. This form allows users to place new prescriptions and request refills. It is structured into clear steps, requiring users to provide essential information to ensure a smooth processing experience. Steps one through four involve submitting insurance details, specifying the shipping method preferred, and detailing any allergies or health conditions. Filling in these sections accurately is crucial; missing information may lead to delays in processing. Payment options are outlined in step three, giving users the choice between checks, money orders, or credit cards, while also reminding them that incomplete payment information can prevent shipment. Additionally, the form features sections for requesting new medications or refills, ensuring that customers know their rights regarding generics and brand-name drugs. Lastly, users are advised to double-check that they have adhered to all instructions before sending the form, as small oversights could obstruct timely access to required medications.

Cigna Tel Drug Fax Example

CIGNA Tel-Drug Prescription Order Form

 

By submitting this form you are representing that the information provided is correct.

 

.

 

 

. Please print all information clearly with black or blue ink.

 

.

Please complete Steps 1, 2, 3 and 4. Then complete Step 5 and/or 6 as needed.

 

Incomplete information may delay processing.

 

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Please enclose payment method and original prescription(s) only. Copies of prescription(s) will not be accepted.

505

Please do not staple any items to this form.

STEP 1: INSURANCE CARDHOLDER INFORMATION

Cardholder ID #

 

 

 

Cardholder’s

 

 

 

 

 

 

TEMPORARY SHIPPING ADDRESS

 

(SEE INSURANCE CARD)

Full Name

 

 

 

 

 

 

 

 

 

(FOR THIS ORDER ONLY)

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

In Care of Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

 

Zip Code (+ 4)

Temp Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home (

)

 

 

Alternate

(

)

 

 

 

 

 

Temp City

 

 

Temp

 

Phone

 

 

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder’s

 

 

 

Cardholder’s

 

 

 

 

 

 

Temp Zip Code

 

Temp Phone

 

Employer

 

 

 

E-mail

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: SHIPPING

 

 

 

 

 

 

 

 

 

STEP 3: PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If this section is left blank, Standard Shipping will be used.

Refrigerated shipments will be expedited at no additional cost.

Check ( ) the box for the Shipping Method of your choice. You are responsible for the cost of SPECIAL SHIPPING.

Shipping Method

# of Days

Cost

Standard Shipping

Standard Delivery

$0.00

USPS PRIORITY MAIL

2-3 Days

$5.25

USPS EXPRESS MAIL

Overnight

$17.95

FEDERAL EXPRESS

Overnight

$17.95

Failure to include complete payment information may delay or prevent shipment of order.

Check ( ) the box for the Payment method of your choice.

Enclosed is a check or money order made payable to CIGNA Tel-Drug.

I authorize CIGNA Tel-Drug to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled: any applicable copayment(s), coinsurance and/or deductible(s), payments due for any medications not covered under my benefit plan, plus any special shipping costs.

Complete credit card information is required for each order.

Check ( ) credit card type and enter corresponding credit card information below.

UPS OVERNIGHT

Overnight (by 12:00 noon)

$17.95

UPS SAVER

Overnight (by 7 pm)

$16.95

SPECIAL SHIPPING expedites carrier delivery time only. Order processing is not affected by SPECIAL SHIPPING. These costs may be subject to change by carrier without prior notification and may vary depending on weight and zone.

American Express

Discover

MasterCard

VISA

Credit

Card #

Expiration

/

Date (MM/YY)

 

 

Name on

 

Credit Card

 

I would like to pay full price for the medication(s) listed below. Do not bill my insurance.

Medication Name and Strength

Medication Name and Strength

584001 Rev. 05/2006

Don’t forget to complete the remaining steps on the reverse side.

STEP 4: ALLERGIES & HEALTH CONDITIONS

Please complete this section every time a medication is ordered.

Patient’s Full Name

Male /

Birth Date

Include nickname, Jr./Sr., etc.

Female

 

 

 

 

 

/

/

 

 

/

/

 

 

/

/

 

 

/

/

 

 

 

 

None

Aspirin

Cephalosporins

Codeine

Erythromycin

Ibuprofen

Penicillin

Sulfa

If no allergies are checked (

), for new customers this

indicates no known allergies

and for existing customers

this indicates no change.

 

 

 

 

Other Allergies

 

Major Health Conditions

 

 

 

 

STEP 5: REFILL PRESCRIPTIONS

For your convenience, you can order refills by calling our automated system at 1.800.TEL.DRUG (835.3784) option 1 or by visiting us at mycigna.com . Do not include refills on this form that you plan to order by phone or Internet. Refills from other pharmacies should not be included on this form.

Patient’s Full Name

Birth Date

CIGNA Tel-Drug Rx Number

Medication Name and Strength

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

 

/

/

Rx#

 

 

 

 

 

 

STEP 6: NEW PRESCRIPTIONS

PHARMACY LAW PERMITS PHARMACISTS TO SUBSTITUTE A LESS EXPENSIVE GENERICALLY EQUIVALENT MEDICATION FOR A BRAND NAME

MEDICATION UNLESS YOU OR YOUR PRESCRIBER INDICATE OTHERWISE. BY CHECKING (

) "BRAND ONLY", YOU MAY INCUR A HIGHER COST.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK ( ) ONE

 

 

CHECK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Full Name

Birth Date

Fill

Do Not

Medication Name & Strength

 

( ) if

Prescriber’s/Physician’s

Prescriber’s/Physician’s

Now

Fill

 

Brand

Full Name

 

Phone Number

 

 

 

Now*

 

 

Only

 

 

/

/

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

(

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/

/

 

 

 

 

 

 

(

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/

/

 

 

 

 

 

 

(

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* By checking this option, you are indicating you do not want the prescription filled at this time. Please contact CIGNA Tel-Drug when the medication is needed.

Thank you for choosing CIGNA Tel-Drug.

You can call us at 1.800.TEL.DRUG (835.3784) or visit us at www.teldrug.com.

You can also write to us or mail this order form to CIGNA Tel-Drug, PO Box 1019, Horsham PA 19044.

At times it may be necessary to switch manufacturers on generic medications. This may cause a change in appearance (size, shape and/or color) of the medication.584001 (BACK) Rev. 05/2006 CIGNA Tel-Drug refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C., operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation.

Form Characteristics

Fact Name Details
Correct Information By submitting the Cigna Tel Drug Fax form, you confirm that all provided information is accurate.
Prescription Submission Only original prescriptions are accepted; copies will not be processed. Ensure to attach your payment method.
Shipping Options Various shipping methods are available, including Standard, USPS Priority, and FedEx, each with different costs and delivery times.
Health Information Complete the allergies and health conditions section each time a medication is ordered to ensure safety.

Guidelines on Utilizing Cigna Tel Drug Fax

Filling out the Cigna Tel Drug Fax form requires careful attention to detail. Each section must be completed thoroughly to ensure timely processing of your prescription request. Please follow the steps outlined below to complete the form accurately.

  1. Insurance Cardholder Information:
    • Enter the Cardholder ID number.
    • Provide the Cardholder's full name for this order.
    • Fill in the temporary shipping address, ensuring you include the in-care-of name, city, state, and zip code.
    • List the Cardholder's contact numbers (home and alternate) and email address.
  2. Shipping:
    • Select your preferred shipping method by checking the appropriate box.
    • Note the cost associated with your chosen shipping method.
  3. Payment:
    • Indicate your payment method: check, money order, or credit card.
    • For credit card payments, check the appropriate box and provide complete credit card information.
    • Specify whether you want to pay full price for the medication without insurance billing.
  4. Allergies & Health Conditions:
    • Enter the patient's full name and date of birth.
    • Check any allergies, including a list of major health conditions if applicable.
  5. Refill Prescriptions:
    • Provide the patient's name, date of birth, CIGNA Tel-Drug Rx number, and medication details for any refills being requested.
  6. New Prescriptions:
    • Fill in the patient's details including name and date of birth.
    • Specify whether a brand name or generic medication is preferred.
    • Provide the prescriber’s name and phone number.

Once you have completed all the sections, ensure all information is clearly printed in black or blue ink. Enclose the original prescription and your method of payment, and avoid stapling any items to the form. You may then submit the completed form to Cigna Tel-Drug using the provided mailing address.

What You Should Know About This Form

What is the Cigna Tel Drug Fax form?

The Cigna Tel Drug Fax form is a document used to order prescription medications and manage refills through Cigna's Tel-Drug service. By completing this form, you provide essential information to ensure that your prescriptions are filled accurately and delivered to you in a timely manner.

How do I fill out the Cigna Tel Drug Fax form?

To complete the form, follow these steps: Start by providing the insurance cardholder's information, including their ID number and temporary shipping address. Next, select your preferred shipping method and indicate your payment choice. After that, fill out the allergies and health conditions section. Finally, complete the sections for refill or new prescriptions. Be sure to print clearly and use black or blue ink to avoid any issues.

What happens if I submit an incomplete form?

If you submit an incomplete form, it may delay the processing of your order. Missing information can result in Cigna needing to contact you for clarification, which takes additional time. To prevent this, double-check all sections before sending your form to ensure that it's complete and accurate.

Are there any specific payment requirements I need to be aware of?

Yes, you'll need to include a payment method with your order. You can either enclose a check or money order, or authorize Cigna to bill your credit card. Be aware that you must also fill out your credit card details completely. Failure to provide the necessary payment information can prevent your order from being processed.

Can I order refills through this form?

This form is not meant for refills you plan to order via phone or online. Instead, you can place refill orders by calling the automated system at 1.800.TEL.DRUG (835.3784) or by visiting mycigna.com. If you intend to refill prescriptions at a pharmacy other than Cigna Tel-Drug, do not include those refills on this form.

What do I need to know about allergies?

It is essential to complete the allergies and health conditions section every time you place an order. This section helps the pharmacy identify any possible allergic reactions to prescribed medications. If you have no known allergies, check the appropriate box to indicate that there are no changes since your last order.

Can I request brand-name medications only?

If you prefer to receive a brand-name medication instead of a generic one, you can indicate this by checking the "Brand Only" box on the form. However, be aware that this choice may lead to a higher cost for you. It is essential to discuss this option with your healthcare provider if you are unsure.

Who should I contact if I have questions about the form?

If you have any questions or need assistance with filling out the form, you can call Cigna Tel-Drug at 1.800.TEL.DRUG (835.3784). Additionally, you can visit their website at www.teldrug.com for further information or to send inquiries via mail to the provided address on the form.

Common mistakes

Filling out the Cigna Tel Drug Fax form can feel like a daunting task, and mistakes can easily happen if you're not careful. One common error is not providing clear and complete information. It’s vital to fill out all sections of the form clearly. Missing or illegible details could slow down the processing time, leaving you without your medication when you need it.

Another mistake arises in omitting the insurance cardholder information. Many people forget to include the cardholder ID number, temporary shipping address, or even the cardholder’s employer and contact information. This information is crucial for billing and shipping and needs to be accurate to avoid complications.

People sometimes overlook the shipping section. If this section is left blank, the default option is standard shipping. This could lead to unnecessary delays if you need your medications urgently. Always check your shipping method to ensure it meets your needs.

The payment information section is another area where errors occur. A common mistake is failing to include complete payment details. Forgetting to indicate a chosen payment method or missing credit card details can hold up your order. Providing full, accurate payment information is essential for timely processing.

Additionally, many individuals neglect to fill out the allergy and health conditions section completely. This section must be filled out each time a medication order is placed. Skipping it can lead to situations where significant allergies aren’t considered, potentially affecting your health.

Refilling prescriptions properly is another tricky area. Some people mistakenly include refills they plan to order through phone or online instead of just filling out new prescriptions. This confusion can complicate your order and lead to unnecessary delays in getting your medications.

The instruction about generic medications can lead to confusion as well. Some individuals forget to indicate whether they want a brand name only or if they are okay with generics. If you do not clarify this preference, it could result in receiving a less preferred medication.

Failing to read through the form carefully before submission can also be problematic. Many people rush through the process, which can lead to errors. Taking the time to double-check all information can save you from delays and potential issues.

Lastly, not enclosing the original prescriptions and proper payment can halt the entire process. It’s essential to remember that copies of prescriptions are not accepted. Be sure to send the originals along with your completed form to avoid any interruptions in your service.

Documents used along the form

The Cigna Tel Drug Fax Form is a critical document used for ordering prescriptions and managing medication shipments. However, it is often accompanied by various forms and documents that help facilitate the process, ensuring accuracy and efficiency. Below is a list of related forms that may be utilized in conjunction with the Cigna Tel Drug Fax form.

  • Insurance Information Form: This form captures detailed information about the patient's health insurance coverage. It typically requires the policy number, group number, and the cardholder's details, allowing for seamless billing and processing.
  • Patient Consent Form: Patients often need to sign a consent form, authorizing the pharmacy to access their health records and share information with their healthcare providers. This document ensures that patient privacy is respected while necessary information is exchanged.
  • Prescription Transfer Form: Should a patient wish to transfer their prescription from another pharmacy, this form is required. It includes information such as the previous pharmacy's name and contact details, allowing for the smooth transition of medications.
  • Medication Information Sheet: Accompanying the prescription, this sheet offers guidance on the medication's purpose, dosage instructions, and potential side effects. It ensures that patients understand how to use their medications safely and effectively.
  • Payment Authorization Form: This form is essential for ensuring transparent payment processes. It reconciles details about how the medications will be paid for, including any insurance billing or out-of-pocket costs incurred by the patient.
  • Allergy Information Form: Patients are typically asked to provide a comprehensive record of any known allergies. This information is crucial in preventing adverse drug reactions and ensures safe medication dispensing by the pharmacist.
  • Refill Authorization Form: For patients who require ongoing medication, this form is used to request refills. It contains patient information and details about the medication being refilled, streamlining the process for both patients and pharmacies.

By understanding these associated forms, patients can better navigate the prescription order and refill process, enhancing communication with their healthcare providers and ensuring they receive the medications they need in a timely manner.

Similar forms

The Cigna Tel Drug Fax Form is utilized primarily for ordering prescriptions, but there are several similar documents that serve comparable purposes in the healthcare landscape. Understanding these can enhance your comprehension of the prescription process. Here are seven documents that mirror aspects of the Cigna Tel Drug Fax Form:

  • Pharmacy Prescription Order Form: Like the Cigna form, this document requests detailed information about the patient, the prescribed medication, and payment methods. Both require clear data entry to ensure accuracy in fulfilling medication orders.
  • Medicare Prescription Drug Form: This document is necessary for Medicare beneficiaries looking to obtain their prescription drugs. Similar to the Cigna form, it collects details such as insurance information and medication specifics to facilitate timely processing.
  • Prior Authorization Request Form: Used when a healthcare provider seeks approval from a health insurance plan before prescribing specific medications. Both forms involve the submission of patient information and the needs associated with medications, emphasizing accuracy to avoid delays.
  • Medication Request Form: This form allows patients or their caregivers to submit requests for medications directly to pharmacies. Much like the Cigna form, it includes sections for recording personal and insurance details, ensuring that the pharmacy has sufficient information to process the order.
  • Refill Request Form: Designed for patients who need to renew their prescriptions, this document usually gathers similar information about medications and the patient's identity. It highlights the importance of maintaining continuity of care, akin to the Cigna form's refill section.
  • Specialty Pharmacy Order Form: This document is specific to specialty medications, which often require additional considerations such as shipping and handling. Like the Cigna form, it includes detailed patient and medication information, alongside payment options.
  • Electronic Prescription (eRx) Request: Digital in nature, this form facilitates the electronic sending of prescriptions directly from the provider to the pharmacy. While it streamlines the process, it shares the same core elements of patient and insurance information as the Cigna form.

By understanding these documents, you can navigate the prescription process more effectively and ensure that your needs or the needs of those you care for are met without unnecessary complications.

Dos and Don'ts

When filling out the Cigna Tel Drug Fax form, here are some guidelines to ensure a smooth process:

  • Do print clearly. Use black or blue ink for all information to prevent errors during processing.
  • Don't skip any steps. Make sure to complete Steps 1 through 6 to avoid delays.
  • Do include original prescriptions. Ensure that you only enclose original documents, as copies will not be accepted.
  • Don't staple materials. Avoid stapling any items to the form to maintain the integrity of the submission.

Following these steps will help to facilitate your order and minimize any potential issues with processing.

Misconceptions

Understanding the Cigna Tel Drug Fax form can be challenging due to several misconceptions. Below is a list of common misunderstandings along with clarifications:

  • All information is optional: Some people believe that they can leave sections blank. In reality, incomplete information may delay processing.
  • Copies of prescriptions are acceptable: There is a misconception that sending a copy of a prescription will suffice. Only original prescriptions will be accepted.
  • Payment information is not necessary upfront: Many think they can submit their order without including payment details. However, failure to provide complete payment information may prevent shipment.
  • Stapling items is allowed: A common myth is that stapling items to the form is acceptable. In fact, it is explicitly stated not to staple any items.
  • All allergies and health conditions can be left blank: Some users may assume that not listing allergies is fine. It is important to complete this section every time a medication is ordered.
  • Generic medication substitution is always possible: A misunderstanding exists that brand-name prescriptions can always be substituted with generics. Check the appropriate box if brand only is desired.
  • Refills can be included on the same form: People often think they can request refills and new prescriptions simultaneously. Refills intended for other pharmacies should not be included.
  • Shipping costs are fixed: Many assume that shipping costs will always be the same. However, shipping costs may vary depending on weight and carrier, and they are subject to change without notice.
  • Contacting customer service is unnecessary: Lastly, some believe they can rely only on the form to complete their order. It’s always a good idea to contact customer service for clarification or assistance.

By addressing these misconceptions, individuals can better navigate the Cigna Tel Drug Fax form and ensure a smoother experience.

Key takeaways

Individuals using the Cigna Tel Drug Fax form should adhere to several key guidelines to ensure a smooth process. Consider the following takeaways:

  • All information must be filled out clearly in black or blue ink.
  • Submit original prescriptions only; copies will not be accepted.
  • Do not staple any documents to the form.
  • Payment information is necessary to avoid delays in processing.
  • Include complete insurance cardholder information, including shipping addresses.
  • It is essential to provide accurate allergy and health condition details for every order.
  • Refills should not be included on this form if ordering via phone or online.
  • Review shipping method options and confirm your selected payment type to expedite delivery.

Following these guidelines will help facilitate timely processing and delivery of medications ordered through Cigna Tel Drug.