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CIGNA Specialty Pharmacy Services Fax Order Form Please deliver by Requests received after 4 p.m. CT will begin processing the following business day Order Fax 1. 8ml - J0135 Crohn s Disease Starter Pack SelfInjectable Pen DIRECTIONS QTY 6 pens Inject four 40mg pens all on one day SC initially and then inject two 40mg pens 2 weeks later and then inject two 40mg pens 2 weeks later REFILLS 0 Other Psoriasis Starter Pack Self-Injec...

Patients should be able to provide their home or office number. All requested patient phone numbers will be stored for up to 1 year until the patient is no longer a patient. 1.877.222.9454 2.800.351.3616 3.1.878.4532 REFERRAL: I can't fill your order by phone. Please make this referral: 3.1.878.4532 Name : (Insert Name Below) 1.800.352.1336 Phone: 1.800.352.1426 Fax: 1.800.354.2822 Please provide the referral number only 1.800.352.1336 1.888.353.2277 3.1.878.4532 (Note: Referral must be made using this link for this patient. Referral cannot be made online.) Fee-Based Insurance Coverage for Prescriptions and Other Items for Patients Over Age 65, May Require Photo ID in Certain States. Some states require additional identification before you can get prescription coverage or other items from a participating pharmacy. To find out if these laws apply to you, please call 1.800.547.8883 and ask for your state. What Can I Write? As a patient who is looking for care, make sure you: Use your real name for your prescription. Don't use a false name or fake address. You must provide your home or office phone number for every order that you submit, unless you provide a referral from your dentist. Write your full name and date of birth. Don't leave extra space or symbols in your name or date of birth. Don't enter any numbers into your order.