Medicare Part D Coverage Decisions
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, please contact us at the following phone numbers:
- Cigna-HealthSpring Rx® Plans: 1-800-222-6700 (TTY 711) 8am-8pm (your local time), 7 days a week.
- Cigna-HealthSpring Medicare Advantage plans: 1-800-331-6293 (TTY 711) 8am-8pm (central time), 7 days a week.
- Cigna-HealthSpring Medicare Advantage plans in Arizona: 1-800-627-7534 (TTY 711) 8am-8pm (Arizona time), 7 days a week (hours apply Monday – Friday, February 15 – September 30).
To request an exception, complete and submit the Coverage Determination Request form(found on the Forms page) and follow the instructions.
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 (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. 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.
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 (found on the Forms page) 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 the Chapter named “What to do if you have a problem or complaint” in your Evidence of Coverage document.
Where to Send an Exception or Coverage Determination Request:
Cigna-HealthSpring – Part CDE
PO Box 20002
Nashville, TN 37202
For more information about coverage determination, visit our customer forms page. For information about the aggregate number of Cigna-HealthSpring grievances, appeals and exceptions or the financial condition of Cigna-HealthSpring, please contact us.