How do I get Cigna to cover a non-formulary drug?

Your prescriber files a formulary exception request with clinical justification — why covered alternatives are inappropriate or have failed. If urgent, request an expedited decision.

Guides · Cigna · appeals · Updated July 2026

How to appeal a Cigna prescription drug (formulary) denial

Cigna denials of prescription drugs usually come down to formulary exclusions, step-therapy ("fail first") rules, or prior-authorization requirements. Each has a defined override process most patients never use.

Why Cigna denies this

Cigna (via Express Scripts) may deny a drug because it's non-formulary, requires trying a cheaper drug first, or lacks prior authorization. The denial often cites code 197 (authorization) or a formulary code. Your prescriber's clinical justification is the lever.

What wins the appeal

Have your prescriber file a formulary exception or step-therapy override request, documenting why formulary alternatives are inappropriate or have failed. For off-label uses, cite compendia support. Appeal within 180 days (65 for Medicare Advantage), and request expedited review if you need the drug urgently.

Your deadline

Depends on your plan type: 180 days for most employer and marketplace plans, 120 for Original Medicare, ~90 for Medicaid, and only 65 for Medicare Advantage. Set it before you do anything else.

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Common questions

How do I get Cigna to cover a non-formulary drug?: Your prescriber files a formulary exception request with clinical justification — why covered alternatives are inappropriate or have failed. If urgent, request an expedited decision.