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: 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)
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
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 (1 (800) 633-4227, 24/7)
- 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
EFT Form - Except Kansas City and Arizona
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
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
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)
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
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267
Medicare Part D Prescription Plans
If not using online form, send to:
Cigna
8455 University Place #HQ2L-04
St. Louis, MO 63121
Or fax to: 1 (866) 845-7267
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 Benefit Change Form – Arizona
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.
Find out more about how appeals work
Medicare Advantage Only Plans - Except Arizona
Write:
Cigna Medicare
Attn: Appeals
P.O. Box 24087
Nashville, TN 37202-4087
Call: 1 (800) 668-3813, 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: 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 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: 1 (800) 931-0149
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
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
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: 1 (800) 668-3813, 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: 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 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: 1 (800) 931-0149
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
Medical Pre-Service Appeal 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
Use when you want to request reimbursement of covered medical costs.
Medicare Advantage Only Plans - Except Arizona
Medical Reimbursement Claim Form
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
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
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
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
Print form and send to:
Cigna
Attn: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
Medicare Part D Prescription Plans
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.
Accounting of PHI Disclosures Form
Use when you want a list of each time we have disclosed your protected health information.
Disagreement/Denial of Amendment Form
Use when you do not agree with our denial of your request to change your protected health information that we have on file.
Restriction of Use and Disclosure of PHI Form
Use when you want to ask for a restriction on the use and disclosure of your protected health information.
Authorization for Disclosure Form
Use when you want to allow the disclosure of specific protected health information to a specific person or entity.
Amend Protected Health Information Form
Use when you want to ask for an amendment to the protected health information that we have on file.
Confidential Communication Form
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
Confidential Communication Form - Vermont
Access to Health Care Information Form
Use when you want to request access to protected health information that we have created or received.
Confidentiality and Disclosure Forms for Victims of Domestic Violence
Request to Revoke a Reasonable Request
Medicare Advantage Plans
Permission To Discuss Limited Health Information With Family And Friends - Medicare Advantage
Use when you want to allow Cigna to share 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
Use when you want to allow Cigna to share limited information about your Cigna Medicare Prescription Drug Plan with family and friends.
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
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 593-4482
Medicare Advantage Plans with Prescription Drug Coverage - Arizona only
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 567-2474
Medicare Part D Prescription Plans
If not using online form, send to:
Cigna
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 593-4482
*Indicates forms also applicable for Group-Sponsored plans