Appeals

Prescription drug appeals: How do I request an appeal?

If you are unhappy with an unfavorable drug coverage decision, you may request an appeal. You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. If your appeal relates to a decision by us to deny a drug that is not on our formulary, your physician must indicate that all the drugs on any tier of our formulary would not be as effective in treating your condition as the requested off-formulary drug or would harm your health. If your appeal relates to a decision by us to deny a drug that has restrictions or coverage limits, your physician must submit a supporting statement for the medical necessity of the drug.

For more details about grievance, drug coverage decisions (including exceptions) and appeals process, refer to Chapter 9 of the Medicare Advantage Plans with Prescription Drug coverage of your EOC or Chapter 7 of the Medicare Advantage Plan without Prescription Drug coverage and the stand-alone Prescription Drug plan of your EOC.  For a standard appeal, you should mail your written appeal request to the address below:

Part D Appeals/Grievances
P.O. Box 24207
Nashville, TN 37202

Toll-free: 1 (866) 845-6962 (TTY: 711)
Toll-free fax: 1 (866) 593-4482
Hours of operation: 8:00 am - 8:00 pm, Monday - Friday

You can request an expedited (fast) appeal if you or your doctor believes that your health could be seriously harmed by waiting up to 7 days for a decision. For an expedited appeal, you should contact us by telephone or fax at the numbers below:

Toll-free: 1 (866) 845-6962 (TTY: 771)
Toll-free fax: 1 (866) 593-4482
Hours of operation: 8:00 am - 8:00 pm, Monday - Friday

Request for Redetermination of Medicare Prescription Drug Denial (PDF form)

Request for Redetermination of Medicare Prescription Drug Denial - (Secure, online form)

Puede recibir este documento (Solicitud de Redeterminación) en español, o hablar con alguien sobre esta información en otros idiomas, sin costo alguno. Llame al 1 (866) 487-4331 (TTY: 711). La llamada es gratis.

What is a Fair Hearing?

A Fair Hearing is a Level 2 Appeal which is filed for Medicaid services only. If we say no to part or all of your Level 1 Appeal, we will send you a letter. If your problem is about a Texas Medicaid service or item, you can ask for a Level 2 Appeal (Fair Hearing). Requests for a Fair Hearing are filed with Cigna-HealthSpring CarePlan but reviewed by the HHSC Appeals Division.

If you want to request a Fair Hearing, you must contact Cigna-HealthSpring CarePlan in writing. We will send your Fair Hearing request to the HHSC Appeals Division. You or your representative must ask for a Fair Hearing within 120 days of the date on the letter telling you we were denying your Level 1 Appeal to our plan. If you have a good reason for being late, the HHSC Appeals Division may extend this deadline for you.

Mail your written request to:
Cigna-HealthSpring CarePlan Appeals
PO Box 211088
Bedford, TX 76095

Toll-free fax: 1 (877) 809-0783

Or you can call Member Services at 1 (877) 653-0327 (TTY: 711), 7 days a week, 8:00 a.m. – 8:00 p.m. We can help you with this request. If you need a fast decision because of your health, you should call Member Services to ask for an expedited Fair Hearing.

After your hearing request is received by the HHSC Appeals Division, you will get a packet of information letting you know the date, time, and location of the hearing. Most Fair Hearings are held by telephone. During the hearing, you or your representative can tell the hearing officer why you need the service that we denied.

The HHSC Appeals Division will give you a final decision within 90 days from the date you asked for the hearing. If you qualify for an expedited Fair Hearing, the HHSC Appeals Division must give you an answer within 72 hours. However, if the HHSC Appeals Division needs to gather more information that may help you, it can take up to 14 more calendar days.

What is an Appointed Representative?

Appointed Representative: An individual either appointed by an enrollee or authorized under State or other applicable law to act on behalf of the enrollee in obtaining a coverage determination or in dealing with any of the levels of the appeals process.

Unless otherwise stated in part 423, subpart M of the Medicare Part D regulations, the appointed representative has all of the rights and responsibilities of an enrollee in obtaining a coverage determination or in dealing with any of the levels of the appeals process, subject to the rules described in part 422, subpart M of the Medicare Part C regulations. The variation of state law is considered when accepting the authority of appointed representatives.

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 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 where you are sending your appeal.

You have the right to file a complaint:

If you have a complaint, you can submit feedback directly to Medicare using the Medicare Complaint form at https://www.medicare.gov/medicarecomplaintform/home.aspx (English) / https://www.medicare.gov/MedicareComplaintForm/home.aspx?language=Spanish (en Español).

Number of grievances, appeals, and exceptions made by members

To obtain the aggregate number of Cigna-HealthSpring CarePlan grievances, appeals, and exceptions, or the financial condition of Cigna-HealthSpring CarePlan, please call us at 1 (877) 653-0327 (TTY: 711), 8:00 am - 8:00 pm Central time, 7 days a week.