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Coverage Decisions For Part D Prescription Drugs
The first time you contact our plan to request that a medical service or Part D prescription drug be covered, you will ask our plan to make a coverage decision.
A medical care coverage decision is a decision made by our plan regarding medical care. This includes asking our plan to authorize, provide, or pay for medical services, including the type or level of services, that you believe you should receive.
A drug coverage decision is a decision our plan makes about the coverage of or the amount our plan will pay for your Part D prescription drugs. This includes asking our plan to make an exception to the way a drug is covered.
An exception is a type of initial drug coverage decision (also called a "coverage determination") involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
Some drugs require prior authorization:
For certain prescription drugs, Cigna-HealthSpring CarePlan requires prior authorization. This means that your doctor must get Cigna-HealthSpring CarePlan’s approval before prescribing it to you. If your doctor does not get approval, the drug may not be covered.
These requirements ensure that our members use these drugs in the most effective way. A team of doctors and pharmacists developed these requirements to help us provide quality coverage to our members.
What if my drug is not on the drug list?
If your prescription is not listed on the drug list, you should first contact Customer Service to be sure it is not covered. If Customer Service confirms that we do not cover your drug, you have 3 options:
You can ask your doctor if you can switch to another drug that is covered by us. If you’d like to give your doctor a list of covered drugs that are used to treat similar medical conditions, please contact Customer Service.
You can ask us to make an exception to cover your drug. For more information, read the following section, “How do I request an exception to the plan’s drug list?”
You can pay out-of-pocket for the drug and request that the plan reimburse you by means of an exceptions request. This does not obligate the plan to reimburse you if the exception request is not approved.
How do I request an exception to the plan’s drug list?
You can ask Cigna-HealthSpring CarePlan to make an exception to our coverage rules. Several types of exceptions are:
You can ask us to cover a drug that is not on our drug list.
You can ask us to waive limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
You can ask us to waive coverage restrictions on your drug. For example, for certain drugs, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. If your drug has a step therapy requirement, you can ask us to waive the coverage restriction.
Generally, we will approve your request for an exception only if the alternative drugs included on the plan’s drug list or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
A prescription drug coverage decision can be made by submitting this form by mail or fax. You may also ask us for a drug coverage decision by phone at 1 (877) 653-0327 (TTY: 711) or by a secure online form.
How do I get reimbursed for a covered prescription drug that I paid for out of pocket?
You may use this form to be reimbursed for a covered prescription drug that you paid for out of pocket.
What is Best Available Evidence?
The Centers for Medicare & Medicaid Services (CMS) requires that all plan sponsors accept evidence presented by a Medicare beneficiary that they are eligible for extra help/ Low Income Subsidy (LIS) even if Medicare records show otherwise. Once a beneficiary submits the Best Available Evidence to Cigna, we will request that CMS update the beneficiary's LIS status in the CMS system.
Acceptable forms of Best Available Evidence include:
A copy of your Medicaid card (if you have one).
A copy of a state document that shows you have Medicaid.
A print-out from a state electronic enrollment file or from your state's Medicaid systems that shows you have Medicaid.
A screen print from the State's Medicaid systems showing Medicaid status.
Other documentation from your state that shows you have Medicaid.
A document from your state that shows you have Medicaid and are getting home- and community-based services.
Social Security Administration (SSA) Award Letter.
An application (SSA publication HI 03094.605) filed by Deemed Eligible confirming that the beneficiary is "automatically eligible for extra help". See a sample notice for application filedhere.
Refer toCMS.gov for more information on BAE Policy by CMS.
Cigna CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.
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