MEDICARE PART D COVERAGE DECISIONS

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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 local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30.

Cigna-HealthSpring Medicare Advantage plans

1-800-668-3813 (TTY 711) 8am-8pm (local 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 use of this form is optional.

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.

If your health requires it, ask us to give you a “fast coverage decision." 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 receive your doctor’s statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor’s statement.

To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision 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.)
  • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

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

If we are using the fast deadlines, we must give you our answer within 24 hours. Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to. If we do not meet this deadline, we are required to send 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 requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request.

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

If we are using the standard deadlines, we must give you our answer within 72 hours. Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor’s statement supporting your request. We will give you our answer sooner if your health requires us to. If we do not meet this deadline, we are required to send 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 provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request.

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

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.

Cigna-HealthSpring - Part CDE

PO Box 20002

Nashville, TN 37202

Fax: 1-866-845-7267


You may also ask us for a coverage determination by phone at:

  • Cigna-HealthSpring Rx Plans: 1-800-222-6700(TTY 711) 8am-8pm local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30.
  • Cigna-HealthSpring Medicare Advantage plans: 1-800-668-3813(TTY 711) 8am-8pm (local 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).

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.