2014 Cigna Medicare Customer Forms

If you are enrolled in a Cigna Medicare Select Plus Rx® (HMO) plan, 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.

Form

Print form and send to:

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

Coverage Determination 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.

Drug 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 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

Print form and send to:

Cigna Pharmacy Management
P.O. Box 42005
Phoenix, AZ 85080-2005

Or fax to: 602-865-1875

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.

Pharmacy Redetermination Request Form

Use when you want to have us reconsider coverage of a Part D 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 from CMS.

 

If not using online form, send to:

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

Medical Pre-service Appeal Form

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.

 PDF Form  | Online Form

If not using online form, send to:

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

Medical Payment Appeal Form

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.

 PDF Form  | Online Form

If not using online form, send to:

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

Appointment of Representative Form

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


 English  |  en Español

Print form and send to:

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

Privacy Forms

Please Note: Forms marked with an asterisk (*) below may NOT be used if you are in an employer 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.

Accounting Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

Disagreement Statement Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

Restriction of Use Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

Authorization for Disclosure Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

Amend PHI Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

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.

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

Access to HealthCare Information Form

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

Print form and send to:

Privacy Office
Cigna
PO Box 188014
Chattanooga, TN 37422

You can read more about your privacy here

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.