Customer Forms
Find the forms you may need to manage your Medicare plan from Cigna.
These forms can help with your Medicare plan from Cigna. 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 from Cigna and need a group plan form, you can:
- Visit
Group Plans Resources - Call the phone number on your Cigna ID card
- Talk to your plan administrator
Questions? Reach us at:
Medicare Advantage Plans:
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):
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):
8 am–8 pm, 7 days a week. Our automated phone system may answer your call during weekends from April 1–Sept. 30.
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).
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
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 Only Plans - Except Arizona
Last Updated 10/01/2022
Print and send form to:
Cigna
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919
Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona
Last Updated 10/01/2022
Print and send form to:
Cigna
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
Last Updated 10/01/2022
Print and send form to:
Cigna
Attn: Payment Control Department
P.O. Box 29030
Phoenix, AZ 85038
Medicare Part D Prescription Plans
Last Updated 10/01/2022
Print and send form to:
Cigna Medicare Prescription Drug Plans
PO Box 269005
Weston, FL 33326-9927
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
Last Updated 10/01/2022
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
Last Updated 10/01/2022
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:
Medicare Part D Prescription Plans
Last Updated 10/01/2022
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to:
Use when you want to add or remove the optional dental benefit to or from your plan.
Note: Benefit does not apply to all plans. Please review your
Last Updated 10/01/2022
For mailing address, call Customer Service at the telephone number listed on your Cigna ID card.
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.
Medicare Advantage Only Plans
Write:
Cigna Medicare
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37202-37422
Call:
April 1 - September 30: Monday - Friday 8 am – 8 pm (messaging service used weekends, after hours, and federal holidays).
Fax:
Last Updated 10/01/2022
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
Attn: Precertification
P.O. Box 20002
Nashville, TN 37202-4087
Call:
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
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37422
Call:
April 1 - September 30: Monday - Friday 8 am - 8 pm (messaging service used weekends, after hours, and federal holidays).
Fax:
Last Updated 10/01/2022
Medicare Advantage Plans - Except Arizona HMO
Last Updated 10/01/2022
Print and send form to:
Cigna
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640
Medicare Advantage Plans - Arizona HMO Only
Last Updated 10/01/2022
Print and send form to:
Cigna
Attn: DMR
PO Box 38639
Phoenix, AZ 85063-8639
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
Last Updated 10/01/2022
Print form and send to:
Cigna
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
Last Updated 10/01/2022
Print form and send to:
Cigna
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Medicare Part D Prescription Plans
Last Updated 10/01/2022
Print form and send to:
Cigna
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Privacy forms help protect your health data. To use a form, please print and send to the address noted on the form.
Use when you want to allow the disclosure of specific protected health information to a specific person or entity.
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:
Use when you want to request access to protected health information that we have created or received.
Last Updated 10/01/2022
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
Last Updated 10/01/2022
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
Last Updated 10/01/2022
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:
Medicare Part D Prescription Plans
Last Updated 10/01/2022
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to:
*Indicates forms also applicable for Group-Sponsored plans
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Medicare Advantage and Medicare Part D Policy Disclaimers
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna contracts 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 Cigna depends on contract renewal.
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.