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Home Medicare Member Resources and ServicesCustomer Forms

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:  (TTY 711)

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

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

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]

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 (, 24/7)
  • 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 Only Plans - Except Arizona

Electronic Fund Transfer Form - Except Kansas City and Arizona [PDF]

Electronic Fund Transfer Form - Kansas City Only [PDF]

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

Electronic Fund Transfer Form – Except Kansas City and Arizona [PDF]

Electronic Fund Transfer Form – Kansas City Only [PDF]

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

Electronic Fund Transfer Form [PDF]

Credit Card Form - Arizona Only [PDF]

Print and send form to:

Cigna
Attn: Payment Control Department
P.O. Box 29030
Phoenix, AZ 85038

Medicare Part D Prescription Plans

Automatic Payment Form (Recurring Direct Debit) [PDF]

Credit Card Form [PDF]

Print and send form to:

Cigna 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

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

Coverage Determination Form [PDF]

Online Form

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

Coverage Determination Form [PDF]

Online Form

If not using online form, send to:

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

Dental Forms

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 Evidence of Coverage (EOC) for benefit details.

Dental Claim Form [PDF]

Dental Benefit Change Form – Arizona [PDF]

For mailing address, call Customer Service at the telephone number listed on your Cigna 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 Medicare
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37202-37422

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]

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
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
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]

Medical Reimbursement Claim Forms*

Use when you want to request reimbursement of covered medical costs.

Medicare Advantage Only Plans - Except Arizona

Medical Reimbursement Claim Form [PDF]

Print and send form to:
Cigna
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Medicare Advantage Plans with Prescription Drug Coverage - Except Arizona

Medical Reimbursement Claim Form [PDF]

Print and send form to:

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona

Medical Reimbursement Claim Form [PDF]

Print and send form to:

Cigna
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]

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

Drug Claim Form [PDF]

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

Medicare Part D Prescription Plans

Drug Claim Form [PDF]

Print form and send to:
Cigna
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 1 we have on file.

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.

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

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

Redetermination Form [PDF]

Online Form

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

Redetermination Form [PDF]

Online Form

If not using online form, send to:
Cigna
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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Customer Plan Links

Choosing a Medicare Plan Community Resources Disaster Policy Enrollment and Eligibility Filing a Grievance Medicare Appeals Process and Exceptions Medicare Coverage Decisions Medicare Disenrollment Organization Determination Pre-Enrollment Disclaimers

Other Cigna Websites

Leon Medical Centers Health Plans Texas Medicaid STAR+PLUS Texas Medicare-Medicaid Plan

Audiences

Individuals and Families Medicare Employers Brokers Providers About Cigna

Solutions for

Health Care Providers Pharmacists Pharmacy Residents Group Plans

Medicare Links

Medicare.gov Medicare Ombudsman Medicare Complaint Form

 Cigna. All rights reserved.

Privacy Legal Medicare Supplement State Disclosures Customer Rights Accessibility Notice of Non-Discrimination Language Assistance [PDF] Report Fraud Sitemap

Medicare Advantage 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. All clinical products and services of the LivingWell Health Centers are either provided by or through clinicians contracted with HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. or employees leased by HS Clinical Services, PC, Bravo Advanced Care Center, PC (PA), Bravo Advanced Care Center, PC (MD) and not by Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.

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 and Texas.

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.

American Retirement Life Insurance Company, Cigna National Health Insurance Company and Loyal American Life Insurance Company do not issue policies in New Mexico.

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 website.

Y0036_22_101121_M | Page last updated 06/01/2022 .