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  • Home Medicare Member Resources and Services Medicare Coverage Decisions and Exceptions

    Medicare Coverage Decisions and Exceptions

    Learn more about Medicare coverage decisions and exceptions such as requirements, forms, and contact information.

    Exceptions and Coverage Decisions

    You may ask for coverage for a medication that is not covered by your plan or has coverage limitations. In this case, you, your doctor, your prescriber, or someone who is acting on your behalf can ask for an exception to our rules (also known as a coverage decision or coverage determination). Here are some examples of exceptions:

    • You ask for a drug that is not on your plan's list of covered drugs (also called a “formulary”). This is a request for a “formulary exception.”
    • You ask for an exception to our plan's utilization management tools—such as dosage limits, quantity limits, prior authorization requirements, or step therapy requirements. Asking for an exception to a utilization management tool is a type of formulary exception.
    • You ask for a non-preferred drug at the preferred cost-sharing level. This is a request for a “tiering exception."
    • You ask us to pay our part of a covered drug you have purchased at an out-of-network pharmacy or other times you have paid the full price for a covered drug under special circumstances.

    Check your plan's Complete Drug List Formulary to see if your requested medication needs a coverage determination.

    Fast Coverage Decisions (Expedited Coverage Determination)

    You can ask us to give you a “fast coverage decision” if you need it for your health. When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we get your doctor’s statement.

    You can get one:

    • Only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
    • Only if using the standard deadlines could cause harm to your health or hurt your ability to function.

    If your doctor or other prescriber tells us that you need a “fast coverage decision” for your health, we will automatically agree to give you a fast coverage decision.

    Who Can Request a Coverage Determination

    You, your prescribing physician, or someone you name can ask us for a coverage determination. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or someone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form (you can find this on the Customer Forms page). This form gives the person legal permission to act as your representative. This statement must be faxed or mailed to us at the designated number or address. The Appointment of Representative form does not have to be filled out if a physician is submitting an exception or coverage determination request.

    Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For more information about exception criteria, you can reach us at:

     (TTY 711)
    8 am - 2 am ET, Monday - Friday and 8 am - 8 pm ET, Saturday

    How to Request a Coverage Determination

    Online Forms

    Request Prescription Drug Coverage Determination

    By Phone

    (TTY 711)
    8 am - 2 am ET, Monday - Friday and 8 am - 8 pm ET, Saturday

    By Mail or Fax

    To ask for an exception, fill out and submit a Coverage Determination Request form. (You can find these forms on the Customer Forms page). Once you’ve filled it out, mail or fax to:

    Cigna Healthcare
    Attn: Medicare Reviews
    PO Box 66571
    St. Louis, MO 63166-6571
    Fax:

    Coverage Decision Deadlines

    For a “Standard Coverage Decision”

    For standard coverage decisions, Cigna HealthcareSM must give you our answer within 72 hours. Generally, this means within 72 hours after we get the request. If you are asking for an exception, we will give you our answer within 72 hours after we get your doctor’s statement supporting your request. We will give you our answer sooner if your health depends on it. If we do not meet this deadline, we must forward your request to be reviewed by an independent organization.

    If we approve your request for coverage, we must give you the coverage we have agreed to provide within 72 hours after receipt of your request or doctor’s statement supporting your request.

    If our answer is no to part or all of what you asked for, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

    For a “Fast Coverage Decision”

    For fast coverage decisions, Cigna Healthcare must give you our answer within 24 hours. Generally, this means within 24 hours after we get the request. If you are asking for an exception, we will give you our answer within 24 hours after we get your doctor’s statement supporting your request. We will give you our answer sooner if your health depends on it. If we do not meet this deadline, we must forward your request to be reviewed by an independent organization.

    If our answer is yes to part or all of what you asked for, we must give you the coverage we have agreed to provide within 24 hours after receipt of your request or doctor’s statement supporting your request.

    If our answer is no to part or all of what you asked for, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

    More Information

    To get more coverage determination information or to find forms, go to Customer Forms. To learn more about the aggregate number of Cigna Healthcare Medicare grievances, appeals, and exceptions or the financial condition of Cigna Healthcare Medicare, please contact us.

    You have the right to file a complaint:

    If you have a complaint, you can send your feedback straight to Medicare using the Medicare Complaint form.

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    AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.

    Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by American Retirement Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Insurance Company, Cigna National Health Insurance Company or Loyal American Life Insurance Company. Each insurer has sole responsibility for its own products.

    The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Rhode Island, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.

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    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

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    Y0036_25_1271910_M | Page last updated 10/01/2024