Coverage Decisions, Appeals & Grievances (en Español)

Exceptions and Coverage Determinations

You, your doctor or someone else who is acting on your behalf can ask for an exception to our rules for coverage such as prior authorization edits, step therapy edits or tiered cost-sharing structure. Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For more detailed information regarding the criteria for exceptions, call Cigna Medicare Rx® Customer Service. To request an exception, complete and submit the Coverage Determination Request form and follow the instructions. If you need help in completing the form, please contact Customer Service -- we will be happy to help you.

The following are examples of coverage determinations:

  • You ask for a Part D drug that is not on your plan's list of covered drugs (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. Requesting an exception to a utilization management tool is a type of formulary exception.
  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."
  • You ask us to pay our portion 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. Prescription Drug Claim Form.
Who may ask for an exception or coverage determination?

You can ask us for a coverage determination yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone 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 that gives the person legal permission to act as your appointed 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 completed if a physician is submitting an exception or coverage determination request.

For information regarding the Medicare Part D Exceptions and Coverage Determination Process, please refer to Chapter 7 of the Evidence of Coverage document

Where to Send an Exception or Coverage Determination Request

 

To contact us by mail:

Call us:

Cigna Pharmacy Services
Medicare Rx (PDP)
P.O. Box 42005
Phoenix, AZ 85080-2005

Phone Number:

1-800-558-9363

TTY/TDD:

711

Fax Number:

1-866-249-1172

Monday - Friday: 8 am - 11 pm EST and

Saturday: 7 am to 6 pm EST

Appeals (Redeterminations)

If our plan makes a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking our plan to review and change a coverage decision we have made. When submitting your appeal you may include information which you believe may help us with the processing of your appeal or help us rule in your favor. Upon completion of our review, a letter will be sent to you advising you of our decision. A standard appeal must be submitted in writing and filed within 60 days from the date that the coverage determination was rendered.

Appeal Form

Expedited Appeals

You or your physician acting on your behalf may request an expedited appeal orally or in writing. If we determine that the request meets the expedited criteria, we will render a decision as expeditiously as your health condition requires but not exceeding 72 hours. If the request does not meet the expedited criteria then we will render a decision within the standard appeal time frame of 7 days.

Who may ask for an appeal?

If you have received a Notice of Denial, and you disagree with the decision rendered, you can ask us for an appeal yourself, or your prescribing physician or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone 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 statement that gives the person legal permission to act as your appointed representative. This statement must be faxed to us at the number below, or you may mail the Appointment of Representative form to us at the address below. The Appointment of Representative form does not have to be completed if a physician is submitting an expedited request.

If you have not received a Notice of Denial, you must file a Coverage Determination Request form before filing an Appeal.

Where to send an Appeal

 

To contact us by mail:

Call us:

Cigna Pharmacy Services
Attention: Medicare Rx (PDP)
Appeals
P.O. Box 42005
Phoenix, AZ 85080-2005

Phone Number:

1-800-222-6700

TTY/TDD:

711

Fax Number:

1-866-945-4631

8 am to 8 pm, local time,

7 days a week

Grievances

A grievance is any dispute expressing dissatisfaction with any aspect of the operations or its activities. Prescription drug plan grievances can be received by customer service representatives via mail, telephone, facsimile or in-person delivery.

In order to exercise this right, you must file your grievance no later than 60 days after the event or incident that precipitates the grievance. Most grievances are answered in 30 days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your grievance. Upon completion of our review, we will let you know by phone or in writing advising you of our decision.

For more information regarding the Medicare Part D Grievance Process, please refer to Chapter 7 of the Evidence of Coverage document.

Where to Send a Grievance

 

To contact us by mail:

Call us:

Cigna Medicare Rx
Attention: Grievance Coordinator
P.O. Box 269005
Weston, FL 33326

Phone Number:

1-800-222-6700

TTY/TDD:

711

Fax Number:

1-800-735-1469

8 am to 8 pm, local time,

7 days a week

More information

For more information about coverage determination, visit our customer forms page. For information about the aggregate number of Cigna Medicare Rx grievances, appeals and exceptions or the financial condition of Cigna Medicare Rx, please contact Customer Service 1-855-391-2556. TTY users call 711, 8 am to 8 pm local time, 7 days a week.

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