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Home Medicare Member Resources and ServicesMedicare Coverage Decisions

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 Drug Prior Authorization Request Forms.

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:

  • 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.

How to Request a Coverage Determination

Online Forms

Medicare Part D Prescription Plans

Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

Medicare Advantage Plans with Prescription Drug Coverage in Arizona

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 Customer Forms page). Once you’ve filled it out, mail or fax to:

Cigna Medicare
Attn: Coverage Determination and Exceptions
PO Box 20002
Nashville, TN 37202
Fax:

Coverage Decision Deadlines

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 Customer Forms. To learn more about the aggregate number of Cigna Medicare grievances, appeals, and exceptions or the financial condition of Cigna 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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Y0036_22_101121_M | Page last updated 06/01/2022 .