Customer 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

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

EFT Form - Kansas City Only

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

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

Credit Card Form

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)

Credit Card Form

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

Coverage Determination Form

Online Form

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

Coverage Determination Form

Online Form

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

Coverage Determination Form

Online Form

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

Dental Benefit Change Form – Arizona

For mailing address, call Customer Service at the telephone number listed on your Cigna ID card.

For certain drugs, Cigna will need prior authorization. This means that you or your prescriber may ask for a coverage decision or exception for the prescribed medication. If you or your prescriber do not get approval, the drug may not be covered.

Drug Prior Authorization 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 - 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

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

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

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

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

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

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

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

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 for Confidentiality

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

Redetermination Form

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: 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
Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Or fax to: 1 (866) 567-2474

Medicare Part D Prescription Plans

Redetermination Form

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: 1 (866) 593-4482