CIGNA Medicare Select Plus Rx^® (HMO) Forms

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

Descargo de responsabilidad antes de la inscripción en CIGNA Medicare Select Plus Rx

Enrollment Form - CIGNA Medicare Select Plus Rx Plans * English | en Español (PDF)

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

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.

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
Attn: Medicare Appeal Department
25500 N. Norterra Dr.
Phoenix, AZ 85085

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

If not using online form, send to:

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

Medical Preservice 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.

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.

PDF
English  |  en Español

Print form and send to:

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

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:

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

Change/Revoke 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:

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

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:

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