2014 Cigna Medicare Customer Forms

If you are enrolled in a Cigna Medicare Rx Prescription Drug Plan (PDP), please find all the forms you will need to help you manage your plan throughout the year. Of course, if you have any questions, please contact us.

 

Please Note: Forms marked with an asterisk (*) below may NOT be used if you are in a group-sponsored plan. If you are in a group plan, please call the phone number on your Cigna ID card or contact your plan administrator if you have questions.

 

Claim & Billing Forms

Prescription Drug Claim Form
Use when you want to request reimbursement
for a medication that you have already paid for.

Print form and send to:

Connecticut General Life Insurance Company
Pharmacy Service Center
P.O. Box 5950
Scranton, PA 18505-5950

Direct Deposit Authorization Form*
Use when you want to authorize us to
automatically deduct your premium from your
bank account.

Print form and send to:

Cigna Medicare Services
PO Box 269005
Weston, FL 33326-9927

Coverage Determination Forms

As indicated below, some forms are available for online submission. To send Cigna a form via the web, simply click on the Online Form link and follow the instructions to enter the appropriate information. If you prefer to fill out and mail the form, click on the PDF Form link.

Coverage Determination Request Form*

Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.
PDF Form | Online Form

You can also download this form directly from CMS

If not using online form, send to:
Cigna Pharmacy Management
P.O. Box 42005
Phoenix, AZ 85080-2005

Or fax to: 602-865-1875

Appointment of Representative Form

Use when you want someone other than yourself to represent you in all matters concerning your coverage determination.

English | en Español

You can also download this form directly from CMS

If not using online form, send to:
Cigna Pharmacy Management
P.O. Box 42005
Phoenix, AZ 85080-2005

Appeal Forms

As indicated below, several forms are available for online submission. To send Cigna a form via the web, simply click on the Online form link and follow the instructions to enter the appropriate information.

If you prefer to fill out and mail the form, click on the PDF link and mail to the address listed below.

Redetermination Request Form*

Use when you want to have us reconsider coverage of a medication after it has been denied via the initial coverage determination process, or when reimbursement has been denied if you have already received the medication.

PDF Form | Online Form

You can also download this form directly from CMS

If not using online form, send to:

Cigna Pharmacy Services
Attention: Medicare Rx (PDP) Appeals
PO Box 42005
Phoenix, AZ 85080-2005

Appointment of Representative Form

Use when you want someone other than yourself to represent you in all matters concerning your appeal.

English |  en Español

You can also download this form directly from CMS

Print form and send to:

Cigna Pharmacy Services
Attention: Medicare Rx (PDP) Appeals
PO Box 42005
Phoenix, AZ 85080-2005

Privacy Forms

Print and send all forms to:

Cigna Medicare Services
PO Box 269005
Weston, FL 33326-9927

Accounting of PHI Disclosures Form

Use when you want an itemized list of each time we have disclosed your protected health information

Disagreement/Denial of Amendment Form

Use when you want to formally disagree with our denial of your request to amend your protected health information that we maintain.

Restriction of Use and Disclosure of PHI Form

Use when you want to request a restriction on the use and disclosure of your protected health information.

Authorization for Disclosure Form

Use when you want to authorize the disclosure of specific protected health information to a specific person or entity.

Amend Protected Health Information Form

Use when you want to request an amendment to the protected health information that we maintain.

Confidential Communication Form

Use when you want to have communications containing protected health information sent to a different address than the one we have on file.

Access to HealthCare Information Form

Use when you want to request access to protected health information that we have created or received.

You can read more about grievances, appeals and exceptions here.

If you have a question about disenrollment, please read about disenrollment here.

To view Physician Exception Forms, click here.

Read more about our Privacy Policy  English | en Español.