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Home Medicare Member Resources and ServicesCustomer Forms

Customer Forms 

Find the forms you may need to manage your Medicare plan.

These forms can help with your Medicare plan from Cigna HealthcareSM. As shown below, some forms can be sent online. To send a form through the web, simply click on the Online Form link and follow the instructions to enter the correct information.

A Note for Group-Sponsored Plans: Only forms with an asterisk (*) also have to do with group-sponsored plans. If you are in a Medicare group plan and need a group plan form, you can:

  • Visit Group Plans Resources
  • Call the phone number on your ID card
  • Talk to your plan administrator

Questions? Reach us at:

Medicare Advantage Plans: (TTY 711)

Oct. 1–Mar. 31: 8 am–8 pm, 7 days a week

April 1–Sept. 30: Mon.–Fri., 8 am–8 pm. Messaging service used weekends, after hours, and federal holidays.

Medicare Advantage Plans (Arizona only): (TTY 711)

Oct. 1–Mar. 31: 8 am–8 pm (Arizona time), 7 days a week

April 1–Sept. 30: Mon.–Fri., 8 am–8 pm (Arizona time). Voicemail available on weekends and federal holidays.

Medicare Prescription Drug Plans (PDP): (TTY 711)

8 am–8 pm, 7 days a week. Our automated phone system may answer your call during weekends from April 1–Sept. 30.

Appointment of Representative Forms*

Use when you want someone other than yourself to stand for you in all matters that have to do with your coverage determination or appeal (see below).

Appointment of Representative Form [PDF]

Last Updated 10/01/2022

You’ll send this form to the same place where you are sending your grievance, coverage determination, or appeal.

If you need more help, you can:

  • Reach out to your Medicare plan
  • Call 1-800-MEDICARE (), 24 hours a day, 7 days a week (except some federal holidays)
  • Contact Us
Automatic Premium Payment Authorization Forms*

Use when you want to allow us to automatically take your premium out of your bank account or charge your premium payment to your credit card.

Medicare Advantage Plans

Sign up for automatic premium payments through your myCigna account.

Medicare Part D Prescription Plans

Automatic Payment Form (Recurring Direct Debit) [PDF]

Credit Card Form [PDF]

Last Updated 10/01/2023

Print and send form to:

Cigna Healthcare Medicare Prescription Drug Plans
PO Box 269005
Weston, FL 33326-9927

Coverage Determination/Exceptions Request Forms

Use when you want to ask for coverage for a medication that is not covered by your plan or has limits on its coverage.

Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

Coverage Determination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:

Cigna Healthcare
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Coverage Determination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:

Cigna Healthcare
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:

Medicare Part D Prescription Plans

Coverage Determination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:

Cigna Healthcare
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:

Dental Forms

Dental Reimbursement Claim Form

Use this form when you want to get reimbursed for a dental benefit that you have already paid for. Once you’ve completed the form, print and mail it to one of the following addresses, depending on which plan you’re enrolled in. Please note that the benefit does not apply to all plans. Review your Evidence of Coverage (EOC) for benefit details.

Dental Reimbursement Claim Form [PDF]

Last Updated 10/01/2022

For Cigna Healthcare Dental Allowance Plans:
Cigna Healthcare Dental-Reimbursement
PO Box 188037
Chattanooga, TN 37422-8037

For Cigna Healthcare DHMO Plans:
Cigna Healthcare Dental-Reimbursement
PO Box 188045
Chattanooga, TN 37422-8045

If your plan’s mailing address is not listed, call Customer Service at the phone number listed on your ID card.

Medical Payment Appeal Forms

You or your appointed representative may ask for an appeal when you want to us to review coverage again, after your first request has been denied. This may be for a medical item or service that you have already received and paid for.

You can call, fax, or write to us.
Find out more about how appeals work

Medicare Advantage Only Plans

Write:
Cigna Healthcare Medicare
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37422

Call: , TTY 711, 8 am – 8 pm, 7 days a week.

April 1 - September 30: Monday - Friday 8 am – 8 pm (messaging service used weekends, after hours, and federal holidays).

Fax: 

Medicare Advantage Member and Representative Appeal Form [PDF]

Last Updated 10/01/2022

Medical Pre-Service Appeal Forms

You or your appointed representative may ask for an appeal when you want to have us re-review coverage of a medical item or service that you have not yet received, after it has been denied through the first organization determination process.

You can call, fax, or write to us.

Medicare Advantage Only Plans - Except Arizona

Write:
Cigna Healthcare
Attn: Precertification
P.O. Box 20002
Nashville, TN 37202-4087

Call: , TTY 711, 8 am - 8 pm, 7 days a week.

April 1 - September 30: Monday - Friday 8 am - 8 pm (messaging service used weekends, after hours, and federal holidays).

Fax: 

Medicare Advantage Plans with Prescription Drug Coverage 

Write:
Cigna Healthcare
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37422

Call: , TTY 711, 8 am - 8 pm, 7 days a week.

April 1 - September 30: Monday - Friday 8 am - 8 pm (messaging service used weekends, after hours, and federal holidays).

Fax: 

Medicare Advantage Member and Representative Appeal Form [PDF]

Last Updated 10/01/2022

Medical Reimbursement Claim Forms*

Medicare Advantage Plans - Except Arizona HMO

Medical Reimbursement Claim Form [PDF]

Last Updated 10/01/2022

Print and send form to:

Cigna Healthcare
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Medicare Advantage Plans - Arizona HMO Only

Medical Reimbursement Claim Form [PDF]

Last Updated 10/01/2022

Print and send form to:

Cigna Healthcare
Attn: DMR
PO Box 38639
Phoenix, AZ 85063-8639

Prescription Drug Claim (Reimbursement) Forms

Use when you want to get reimbursed for a medication that you have already paid for.

Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

Drug Claim Form [PDF]

Last Updated 10/01/2022

Print form and send to:
Cigna Healthcare
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Drug Claim Form [PDF]

Last Updated 10/01/2022

Print form and send to:
Cigna Healthcare
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Medicare Part D Prescription Plans

Drug Claim Form [PDF]

Last Updated 10/01/2022

Print form and send to:
Cigna Healthcare
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718

Privacy Forms

Privacy forms help protect your health data. To use a form, please print and send to the address noted on the form.

Authorization for Disclosure Form [PDF]

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

Confidential Communication Form [PDF]

Use when you want to have messages with protected health information sent to a different address than the one we have on file.

Last Updated 10/01/2022

If you live in Oregon or Vermont, please use one of the forms below:

Confidential Communication Form - Oregon [PDF]

Confidential Communication Form - Vermont [PDF]

Access to Health Care Information Form [PDF]

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

Last Updated 10/01/2022

Redetermination Request Forms

Use when you want us to re-review coverage of a medication or a payment/reimbursement request after it has been denied.

Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

Redetermination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:
Cigna Healthcare
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Redetermination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:
Cigna Healthcare
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:

Medicare Part D Prescription Plans

Redetermination Form [PDF]

Online Form

Last Updated 10/01/2022

If not using online form, send to:
Cigna Healthcare
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:

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*Indicates forms also applicable for Group-Sponsored plans

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Medicare Advantage and Medicare Part D Policy Disclaimers

Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by The Cigna Group Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal.

To file a marketing complaint, contact Cigna Healthcare or call 1-800-MEDICARE (), 24 hours a day, 365 days a year, TTY . Please include the agent/broker name if possible.

Medicare Supplement Policy Disclaimers

Medicare Supplement website content not approved for use in: Oregon.

AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.

Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by Cigna National Health Insurance Company, Cigna Health and Life Insurance Company, American Retirement Life Insurance Company or Loyal American Life Insurance Company. Each insurer has sole responsibility for its own products.

The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.

This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Please refer to the policy for the full terms and conditions of coverage.

In Kentucky, Plans A, F, G, HDG, N are available under Cigna National Health Insurance Company, Plans A, F, G, HDF, N are available under Cigna Health and Life Insurance Company and Plans A, B, C, D, F, G, N are available under Loyal American Life Insurance Company.

Kansas Disclosures, Exclusions and Limitations

Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website.

Y0036_24_1037312_M | Page last updated 10/15/2023