Customer Forms

2020 Cigna Customer Forms

If you are enrolled in a Medicare plan from Cigna, please find all the forms you will need to help you manage your plan throughout the year. Of course, if you have any questions, please call us at:

Medicare Advantage Plans: 1 (800) 668-3813 (TTY 711)

Medicare Advantage Plans (Arizona Only): 1 (800) 627-7534 (TTY 711)

Medicare Prescription Drug Plans (PDP): 1 (800) 222-6700 (TTY 711)

For certain medications, Cigna requires prior authorization. This means that you or your prescriber may request a coverage decision or exception for the prescribed medication. If you or your prescriber do not obtain approval, the drug may not be covered.

Drug Prior Authorization Forms

Customer Forms

These forms are related to your Medicare plan from Cigna. As indicated below, some forms are available for online submission. To send a form via the web, simply click on the Online Form link and follow the instructions to enter the appropriate information.

A Note for Group-Sponsored Plans: Only forms with an asterisk(*) also apply to group-sponsored plans. If you are in a Medicare group plan from Cigna and need a group plan form, please visit Employer Group Customer Tools and Resources, call the telephone number on your Cigna ID card, or contact your plan administrator.

Appointment of Representative Forms^*

Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Representative Form
Nombramiento de un Representante

Send this form to the same location where you are sending your grievance, coverage determination, or appeal.

If you need more help, you can:

Contact your Medicare plan
Call 1-800-MEDICARE (1 (800) 633-4227, 24 hours a day, 7 days a week)
Contact Us

Automatic Premium Payment Authorization Forms

Use when you want to authorize us to automatically deduct your premium from your bank account or charge your premium payment to your credit card.

Medicare Advantage Only Plans – Except Arizona

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

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

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

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

EFT Form

Formulario de Transferencia Electrónica de Fondos

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

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)

Formulario de autorización de débito directo periódico

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

Print and send form to:

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

Coverage Determination Request Forms

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

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de medicare

If not using online form, send to:

Cigna Coverage Determinations and Exceptions
P.O. Box 20002
Nashville, TN 37202
Or fax to: 1 (866) 845-7267

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de Medicare

If not using online form, send to:

Cigna
Pharmacy Coverage
Determinations & Exceptions
P.O. Box 20002
Nashville, TN 37202
Or fax to: 1 (866) 845-7267

Medicare Part D Prescription Plans

Coverage Determination Form

Online Form

Solicitud de determinación de cobertura para medicamentos con receta de Medicare

If not using online form, send to:

Cigna
Attn: Coverage Determinations & Exceptions
PO Box 20002
Nashville, TN 37202
Or fax to: 1 (866) 845-7267

Medical Payment Appeal Forms

You or your appointed representative may request an appeal 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.

You can call, fax, or write to us.
Find out more information about the appeals process.

Medicare Advantage Only Plans – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Call:1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm (Local time), 7 days a week. April 1 – September 30: Monday – Friday 8:00 am – 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Call: 1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm Local time, 7 days a week. April 1 – September 30: Monday – Friday 8:00 am - 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax: 1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Medical Payment Appeal Form

Online Form

If not using online form, send to:

Cigna
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1 (866) 567-2474

Medical Pre-Service Appeal Forms

You or your appointed representative may request an appeal 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 process.

You can call, fax, or write to us.
Find out more information about the appeals process.

Medicare Advantage Only Plans – Except Arizona

Write:

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

Call: 1 (800) 668-3813, TTY 711, 8:00 am – 8:00 pm Local time, 7 days a week. April 1 – September 30: Monday – Friday 8:00 am – 8:00 pm Local time (messaging service used weekends, after hours, and Federal holidays).

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Write:

Cigna
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087

Fax:1 (800) 931-0149

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Medical Pre-Service Appeal Form

Online Form

If not using online form, send to:

Cigna
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1 (866) 567-2474

Medical Reimbursement Claim Forms^*

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

Medicare Advantage Only Plans – Except Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

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

Formulario de reclamo para solicitud de reembolso del miembro inscrito

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

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna
Attn: Medicare Claims
25500 Norterra Pkwy Building B
Phoenix, AZ 85085

Prescription Drug Claim (Reimbursement) Forms

Use when you want to request reimbursement for a medication that you have already paid for.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna
Attn: Direct Member Reimbursement, Pharmacy
P.O. Box 20002
Nashville, TN 37202

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna
Attn: Direct Member Reimbursement
P.O. Box 20002
Nashville, TN 37202

Medicare Part D Prescription Plans

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

Cigna
Attn: Direct Member Reimbursement, Pharmacy
P.O. Box 20002
Nashville, TN 37202

Privacy Forms

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

Accounting of PHI Disclosures Form / Solicitud de historial de divulgaciones de información sobre la salud protegida
Use when you want an itemized list of each time we have disclosed your protected health information

Disagreement/Denial of Amendment Form / Manifestación de desacuerdo/Solicitud para que se envíe el rechazo de la solicitud de modificación
Use when you want to formally disagree with our denial of your request to amend your protected health information that we maintain.

Restriction of Use and Disclosure of PHI Form / Solicitud de restricción de uso y divulgación de Información sobre la salud protegida
Use when you want to request a restriction on the use and disclosure of your protected health information.

Authorization for Disclosure Form / Autorización de divulgación de Información sobre la salud protegida
Use when you want to authorize the disclosure of specific protected health information to a specific person or entity.

Amend Protected Health Information Form / Solicitud para modificar Información sobre la salud protegida
Use when you want to request an amendment to the protected health information that we maintain.

Confidential Communication Form / Solicitud de comunicaciones confidenciales
Use when you want to have communications containing protected health information sent to a different address than the one we have on file.

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

Confidential Communication Form - Oregon

Confidential Communication Form - Vermont

Access to Health Care Information Form / Solicitud de acceso a Información sobre atención médica
Use when you want to request access to protected health information that we have created or received.

Confidentiality and Disclosure Protocol Forms for Victims of Domestic Violence
Request for Confidentiality

Request to Revoke a Reasonable Request

Medicare Advantage Plans

Permission To Discuss Limited Health Information With Family And Friends - Medicare Advantage / Permiso para Conversar sobre Información sobre la Salud Limitada con Familiares y Amigos de Medicare Advantage
Use when you want to give permission to Cigna to discuss limited information about your Medicare Advantage Plan with family and friends.

Medicare Part D Prescription Plans

Permission To Discuss Limited Health Information With Family And Friends - Part D / Permiso para Conversar sobre Información sobre la Salud Limitada con Familiares y Amigos de Medicare Parte D
Use when you want to give permission to Cigna to discuss limited information about your Cigna Medicare Prescription Drug Plan with family and friends.

Redetermination Request Forms

Use when you want us to reconsider 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

Online Form

If not using online form, send to:

Cigna
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1 (866) 593-4482

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Redetermination Form

Online Form

If not using online form, send to:

Cigna
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1 (866) 567-2474

Medicare Part D Prescription Plans

Redetermination Form

Online Form

If not using online form, send to:

Cigna
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1 (866) 593-4482

Language Assistance

Disclaimers

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.

Medicare Supplement Policy Disclaimers

Website not approved for use in: Colorado, Florida, Montana, North Dakota, and Oregon.

AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST.

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 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 Connecticut, Maryland, Oklahoma & Texas; Plans A, F & N in California; Plans A & C in Michigan; Plans A & F in North Carolina; and Plan C in New Jersey for individuals aged 50-64.

Selecting these links will take you away from Cigna Medicare Advantage and Medicare Part D Prescription Drug Plan information.

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