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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* |
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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. 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. |
| Claim & Billing Forms | |
|
Print form and send to: Connecticut General Life Insurance Company |
|
Print form and send to: CIGNA Medicare Services |
| Coverage Determination Forms | |
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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. |
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Coverage Determination Request Form*Use when you want to request coverage for a medication that is not covered or has limitations on its coverage. |
If not using online form, send to: CIGNA Pharmacy Management |
Appointment of Representative FormUse when you want someone other than yourself to represent you in all matters concerning your coverage determination. PDF |
Print form and send to: CIGNA Pharmacy Services |
| 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. |
If not using online form, send to: CIGNA Pharmacy Services |
Appointment of Representative FormUse when you want someone other than yourself to represent you in all matters concerning your appeal. PDF |
Print form and send to: CIGNA Pharmacy Services |
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.
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
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
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
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
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
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
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
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
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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