Arizona Document Library

• Master Application (PDF)
• Medical Questionnaire 2-24 enrollees (PDF)
• Medical Questionnaire 25-50 enrollees (PDF)
• Member Application (PDF)
• Waivers (PDF)
• Quarterly tax and wage*
• Prior Carrier bill*
• Binder Check*
• CAF-1 (PDF)
• CAF-4 (PDF)

*These documents need to be provided by the employer/plan sponsor to CIGNA that must be submitted with a new case.

• Open Access Plus (OAP) L: 20% / 250 (PDF)
• Open Access Plus (OAP) M: 25% / 500 (PDF)
• Open Access Plus (OAP) N: 25% / 1000 (PDF)
• Open Access Plus (OAP) O: 25% / 2000 (PDF)
• HMO F: 15% / 250 (PDF)
• HMO G: 20% / 500 (PDF)
• HMO H: 25% / 1000 (PDF)
• HMO I: 30% / 2000 (PDF)
• Open Access POS A: 15% / 250 (PDF)
• Open Access POS B: 20% / 500 (PDF)
• Open Access POS C: 25% / 1000 (PDF)
• Open Access POS K: 30% / 2000 (PDF)
• PPO D: 80%/500 (PDF)
• High Deductible Health Plan (HDHP) 1:
  90% / 2000 (PDF)
• High Deductible Health Plan (HDHP) 2:
  90% / 2500 (PDF)
• High Deductible Health Plan (HDHP) 3:
  90% / 3000 (PDF)
• High Deductible Health Plan (HDHP) 4:
  100% / 3000 (PDF)

• Claim form (PDF)
• Supplemental Medical Questionnaire (PDF)
• Discretionary Claim Authority (PDF)
• Conditional Receipt (PDF)
• Transition of Care (PDF)
• Pharmacy Claim (PDF)
• Enrollment Form (Spanish) (PDF)