2012 CIGNA Medicare Rx^® (PDP) Customer Center

Documents

Summary of Benefits

Evidence of Coverage

This document provides you comprehensive information about your coverage in the CIGNA Medicare Rx plans

To view your Evidence of Coverage document, select the appropriate document below.

CIGNA Medicare Rx - Plan One: English | en Español (PDF)
CIGNA Medicare Rx - Plan Two: English | en Español (PDF)

Annual Notice of Change for 2012

This section is for individuals who were enrolled in a CIGNA Medicare Rx plan in 2011. The Annual Notice of Change (ANOC) will tell you how your benefits and costs will change on January 1, 2012.

2011 Plan One customers staying in Plan One for 2012
This booklet will tell you how your benefits and costs will change in 2012 if you stay in Plan One in 2012.

2011 Plan Two customers staying in Plan Two for 2012

This booklet will tell you how your benefits and costs will change in 2012 if you stay in Plan Two in 2012.

2011 Plan Two customers in states where Plan One will join with Plan Two for 2012

This booklet will tell you how your benefits and costs will change in 2012 if you are enrolled in Plan Two in 2011. Plan One and Plan Two will be joining together in certain states. To see if this change applies to your state, click on the drop-down menu below.

Forms

Please Note: Forms marked with an "*" 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.

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

Miscellaneous Forms

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.

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

Other Important Information

Rewards & discounts - Learn more about the EXTRAs you get when you enroll in a CIGNA Medicare Rx plan.

Extra help with prescription drug plan costs - You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, 7 days a week.
• The Social Security Administration at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY/TDD users should call 1-800-325-0778.
• Your State Medicaid Office

Grievances - Information about filing a complaint about the benefits, services, or prescription drug coverage you have received through CIGNA Medicare Rx.

Disenrollment - How to disenroll from CIGNA Medicare Rx

Non-network claims - On occasion, due to travel and emergencies, you may have to use a non-network pharmacy and need to file a paper claim (PDF). Or you may have mistakenly paid full price for an in-network prescription. Follow the instructions on the claim form to ensure proper reimbursement.

Understanding Your Coverage: Medicare Part B vs. Part D
CIGNA Medicare Rx Medicare Part B vs. Part D (PDF)