Medicare Advantage (Part C) Forms

These forms are related to your Medicare Advantage plan, or the Part D portion of your Medicare Advantage Plan.

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

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

Perscription Drug Claim Form
Print form and send to:

Cigna HealthSpring Pharmacy Services
Attn: Direct Memeber Reimbursement
P.O. Box 20002
Nashville,TN 37202
EFT Authorization Form*
Use when you want to authorize us to automatically deduct your premium from your bank account.

EFT Form - English
EFT Form - en Español
Print and send form to:

Cigna-HealthSpring
Attn: MAS - Premium Billing
P.O. Box 200012
Nashville,TN 37202-9919
Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form

Online Form
If not using online form, send to:

Cigna HealthSpring Pharmacy Services
Attn: Part D Coverage Determinations and Exceptions
P.O. Box 20002
Nashville, Tennessee 37202
Or fax to: 1-866-845-7267
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.

Redetermination Form

Online Form
If not using online form, send to:

Cigna-HealthSpring
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1-866-593-4482
Appointment of Representative Form
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Rep Form - English
Appointment of Rep Form - Español
Send this form to the same location where you are sending your appeal if you are filing an appeal, grievance if you are filing a grievance, or initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227).
Medical Pre-service & Payment Appeals (Organizational Determinations)

Click here to learn how to submit an organizational determination request

Write:
Cigna-HealthSpring
Attn: Precertification
P.O. Box 20002
Nashville, TN 37202-4087

Call: 8 am to 8 pm (your local time),(TTY 711), 7 days a week

Fax: 1-800-931-0149
Medicare Advantage (Part C) Forms (Arizona only)

These forms are related to your Cigna Medicare Advantage (in Arizona ONLY), or the Part D portion of your Medicare Advantage plan.

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

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

Prescription Drug Claim Form
Print form and send to:

Cigna Medicare Services
Attn: Direct Member Reimbursement
P.O. Box 20002
Nashville, TN 37202
EFT Authorization Form
Use when you want to authorize us to automatically deduct your premium from your bank account or credit card.

EFT Form - English
EFT Form - en Español
Credit Card Form - English
Credit Card Form - en Español
Print and send form to:
Cigna
Attn: Payment Control Department
P.O. Box 29030
Phoenix,AZ 85038-9971
Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form
Online Form
If not using online form, send to:

Cigna-HealthSpring
Attn: CDE
P.O. Box 20002
Nashville,TN 37202
Or fax to 1-866-845-7267
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.

Redetermination Form
Online Form
If not using online form, send to:

Cigna Medicare Services
Attention: Medicare Appeal Department
25500 N. Norterra Dr.
Phoenix, AZ 85085

Or fax to: 1-866-567-2474
Appointment of Representative Form
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Rep Form - English
Appointment of Rep Form - Español
Send this form to the same location where you are sending your appeal, grievance or initial determination or decision.
Medical Pre-service Appeal Form (Organizational Determination)
Use when you want to have us reconsider coverage of a medical item or service that you have not yet received after it has been denied via the initial organization determination process.

Medical Pre-Service Appeal Form
Online Form
If not using online form, send to:

Cigna Medicare Services
Attention: Medicare Claims Department
25500 N. Norterra Dr.
Phoenix, AZ 85085

Or fax to: 1-866-567-2474
Medcal Payment Appeal Form (Organizational Determination)
Use when you want to have us reconsider coverage of a medical item or service that you have already received and paid for after your initial request has been denied.

Medical Payment Appeal Form (Organizational Determination)
Online Form
If not using online form, send to:

Cigna Medicare Services
Attention: Medicare Claims Department
25500 N. Norterra Dr.
Phoenix, AZ 85085

Or fax to: 1-866-567-2474
Prescription Drug Plans (Part D) Forms

These forms are related to your stand-alone Part D plan.

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

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

Prescription Drug Claim Form
Print form and send to:

Cigna-HealthSpring Pharmacy Services
Attn: Direct Member Reimbursement
P.O. Box 20002
Nashville, TN 37202
EFT Authorization Form*
Use when you want to authorize us to
automatically deduct your premium from your bank account.

EFT Form
Print form and send to:

Cigna-HealthSpring
PO Box 269005
Weston, FL 33326-9927
Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form
Online Form
If not using online form, send to:

Cigna-HealthSpring Pharmacy Services
Attn: Part D Coverage Determinations and Exceptions
PO Box 20002
Nashville, TN 37202
Or fax to: 1-866-845-7267
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.

Redetermination Form
Online Form

If not using online form, send to:

Cigna-HealthSpring
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1-866-593-4482

Appointment of Representative Form
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal.

Links directly to the CMS form:

Appointment of Rep Form - Enlgish
Appointment of Rep Form - Español

Send this form to the same location where you are sending your appeal if you are filing an appeal, grievance if you are filing a grievance, or initial determination or decision if you are requesting an initial determination or decision.


If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227).

Privacy Forms

These forms are related to your business dealings with Cigna-HealthSpring. To use a form, please print and send to the address noted on the form.

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.

Permission to Share Limited Health Information

Use when you want to allow limited health information to be discussed with certain people.

Prior Authorization Forms for Physicians

For certain prescription drugs, Cigna-HealthSpring requires prior authorization. This means that your doctor must get Cigna-HealthSpring’s approval before prescribing it to you. If your doctor does not get approval, the drug may not be covered.

General Forms
Drug/Class Specific Forms