Exceptions and Coverage DecisionsYou 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: Show
To see if your requested medication needs a coverage determination, visitDrug 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:
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 (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:
Online FormsMedicare Part D Prescription Plans Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona Medicare Advantage Plans with Prescription Drug Coverage in Arizona By Phone
By Mail or FaxTo 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 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 InformationTo 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. What is a coverage determination request?A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you'll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.
Is Cigna Medicare the same as CignaSECTION 1 We Are Changing the Plan's Name
On January 1, 2021, our plan name will change from Cigna-HealthSpring Advantage (HMO) to Cigna Fundamental Medicare (HMO).
What is a Cigna AOR form? Complete this section only if someone other than the covered person is appealing. The covered person may represent himself, or may ask another person, including the.
What is the turnaround time for a standard coverage determination?Standard coverage decision
In most cases, 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 it.
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Cigna healthspring medicare general coverage determination form
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