Medicare Coverage Decisions
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.
To see if your requested medication needs a coverage determination, visit
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.
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 (
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:
-
Cigna Medicare Prescription Drug Plans:
(TTY 711)
8:00 am - 8:00 pm, 7 days a week.
Our automated phone system may answer your call during weekends from April 1 - September 30. -
Cigna Medicare Advantage Plans - Except Arizona:
(TTY 711)
October 1 - March 31, 8:00 am - 8:00 pm, 7 days a week.
April 1 - September 30, 8:00 am - 8:00 pm, Monday - Friday.
Messaging service used weekends, after hours, and federal holidays. -
Cigna Medicare Advantage Plans in Arizona:
(TTY 711)
October 1 - March 31, 8:00 am - 8:00 pm, 7 days a week.
April 1 - September 30, 8:00 am - 8:00 pm, Monday - Friday.
Voicemail system is available on weekends and holidays.
Online Forms
By Phone
-
Cigna Medicare Prescription Drug Plans
(TTY 711)
8:00 am - 8:00 pm, 7 days a week.
Our automated phone system may answer your call during weekends from April 1 - September 30. -
Cigna Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona
(TTY 711)
October 1 - March 31, 8:00 am - 8:00 pm, 7 days a week.
April 1 - September 30, Monday - Friday 8:00 am - 8:00 pm.
Messaging service used weekends, after hours, and federal holidays. -
Cigna Medicare Advantage Plans with Prescription Drug Coverage in Arizona
(TTY 711)
October 1 - March 31, 7 days a week, 8:00 am - 8:00 pm.
April 1 - September 30, Monday - Friday, 8:00 am - 8:00 pm.
Voicemail system is available on weekends and holidays.
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
Cigna Medicare
Attn: Coverage Determination and Exceptions
PO Box 20002
Nashville, TN 37202
Fax:
For a “Standard Coverage Decision”
For standard coverage decisions, Cigna 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 move your request on to Level 2 of the appeals process, where it will 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 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 move your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside 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
You have the right to file a complaint:
If you have a complaint, you can send your feedback straight to Medicare using the
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Información legal sobre las pólizas del Seguro Suplementario de Medicare
El contenido del sitio web del Suplemento de Medicare no está aprobado para su uso en Oregon.
LA DESCRIPCIÓN DE LA COBERTURA ESTÁ DISPONIBLE MEDIANTE SOLICITUD. Ofrecemos una descripción de la cobertura a todas las personas al momento de presentar la solicitud.
Nuestra compañía y nuestros agentes no tienen ninguna relación ni respaldo del gobierno de los EE. UU. ni del programa federal Medicare. Esta es una solicitud de seguro. Un agente de seguros podría comunicarse contigo.La prima y los beneficios varían según el plan seleccionado. La disponibilidad del plan varía según el estado. Las pólizas del Suplemento de Medicare están suscritas por Cigna National Health Insurance Company, Cigna Health and Life Insurance Company, American Retirement Life Insurance Company o Loyal American Life Insurance Company. Cada aseguradora es exclusivamente responsable por sus propios productos.
Los siguientes Planes Suplementarios de Medicare están disponibles para personas elegibles para Medicare debido a una discapacidad: Plan A en Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Texas y Virginia; Planes A, F y G en North Carolina y Planes C y D en New Jersey para individuos de 50 a 64 años de edad. Las pólizas del Suplemento de Medicare tienen exclusiones, limitaciones y términos según los cuales las pólizas podrían seguir vigentes o discontinuarse. Para conocer los costos y todos los detalles de la cobertura, comunícate con la compañía.
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Divulgaciones, exclusiones y limitaciones de Kansas
Formularios de póliza del suplemento de Medicare: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS
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Los beneficios de esta póliza no duplicarán los beneficios pagados por Medicare. Los beneficios combinados de esta póliza y los beneficios pagados por Medicare no pueden superar el cien por ciento (100%) de los gastos elegibles para Medicare en los que se haya incurrido. Esta póliza no pagará beneficios en los siguientes casos:
(1) el deducible de Medicare Parte B;
(2) cualquier gasto que no estés obligado legalmente a pagar, o servicios por los cuales habitualmente no se cobra en ausencia de seguro;
(3) cualquier servicio que no sea médicamente necesario según lo determine Medicare;
(4) cualquier parte de cualquier gasto para el cual Medicare u otros programas gubernamentales (excepto Medicaid) realicen el pago o para el cual Medicare hubiera hecho el pago si estuvieras inscrito en las Partes A y B de Medicare;
(5) cualquier tipo de gasto que no sea un gasto elegible de Medicare excepto por lo estipulado previamente en esta póliza;
(6) cualquier deducible, coseguro o copago no cubierto por Medicare, a menos que esa cobertura aparezca como un beneficio en esta póliza; o
(7) Condiciones preexistentes: No pagaremos ningún gasto incurrido por el cuidado o el tratamiento de una condición preexistente durante los primeros seis (6) meses a partir de la fecha de inicio de la cobertura. Esta exclusión no se aplica si solicitaste y te emitieron esta póliza con un estatus de emisión garantizada, si en la fecha de la solicitud de esta póliza tenías al menos seis (6) meses de cobertura acreditable anterior o si esta póliza reemplaza a otra póliza de Seguro Suplementario de Medicare y ya se ha cumplido un período de espera de seis (6) meses. Debes haber informado la evidencia de cobertura anterior o reemplazo en la solicitud de esta póliza. Si tuviste menos de seis (6) meses de cobertura acreditable anterior, la limitación para condiciones preexistentes se reducirá por el monto total de la cobertura acreditable. Si esta póliza reemplaza a otra póliza de Seguro Suplementario de Medicare, se otorgará crédito por cualquier parte del período de espera que se haya cumplido.
Y3006_22_101121_M | Última actualización de la página 1 de junio del 2022.