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2012 CIGNA Medicare Rx® (PDP) Forms

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.


CIGNA Medicare Rx Forms

Enrollment Forms*

Prior to enrolling in CIGNA Medicare Rx, please review the CIGNA Medicare Rx pre-enrollment disclaimer.

Descargo de responsabilidad antes de la inscripción en CIGNA Medicare Rx.

If you live in: AK, CA, CO, DE, DC, GA, HI, ID, KS, LA, ME, MD, MS, NV, NH, NJ, NM, NY, OK, OR, UT, WA, WI.
English | en Español

If you live in: AL, AZ, AR, CT, FL, IL, IN, IA, KY, MA, MI, MN, MO, MT, NE, NC,ND, OH, PA, RI, SC, SD, TN, TX, VT, VA, WV, WY.
English | en Español


Claim & Billing Forms
Pharmacy 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

Payment 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, 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.

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

If not using online form, send to:

CIGNA Pharmacy Management
P.O. 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 coverage determination.

PDF
English  |  en Español

Print form and send to:

CIGNA Pharmacy Services
Attention: Medicare Rx (PDP) Appeals
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

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.

PDF
English  |  en Español

Print form and send to:

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


Privacy Forms

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.

PDF icon Accounting Form

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

Print form and send to:

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

PDF icon 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:

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

PDF icon Revoke Change Form

Use when you want to change or revoke a previously-approved Request for Restriction, Confidential Communication, Personal Representative, Authorization or Statement of Disagreement.

Print form and send to:

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

PDF icon 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:

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

PDF icon 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:

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

PDF icon Amend PHI Form

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

Print form and send to:

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

PDF icon 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:

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

PDF icon Personal Representative Request Form*

Use when you want to enable a person other than yourself to act on your behalf with respect to your CIGNA Medicare plan.

Print form and send to:

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

PDF icon 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:

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



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