Customer Forms

Appointment of Representative Form^*

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]

Last Updated 10/01/2025

Print and mail the Appointment of Representative Form to the address your plan uses for grievances, coverage determinations or appeals.

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

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 Plans

Sign up for automatic premium payments through your myHealthSpring account.

Medicare Part D Prescription Plans

Automatic Payment Form (Recurring Direct Debit) [PDF]

Credit Card Form [PDF]

Last Updated 10/01/2025

Print PDF form and send to:

HealthSpring Medicare Prescription Drug Plans
P.O. Box 269005
Weston, FL 33326-9927

Coverage Determination Request Form

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

Coverage Determination Request Form [PDF]

Last Updated 12/18/2025

Print Coverage Determination Request Form PDF and send to:
Express Scripts
Attn: HealthSpring Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

Fax: 1-866-845-7267

Dental Forms

Dental Reimbursement Claim Form

You can use either of the Dental Reimbursement Claim Forms below when you want to get reimbursed for a dental benefit that you have already paid for.

Medicare Advantage Dental Reimbursement Claim Form [PDF]

Last Updated 11/11/2025

American Dental Association (ADA) Dental Reimbursement Claim Form [PDF]

To request reimbursement, print and complete either form, along with your proof of payment and itemized statement. If you need assistance with filling out the form, you can bring it to your provider's office.

For Dental Allowance Plans, print PDF form and send to:
Cigna Healthcare Dental - Reimbursement
P.O. Box 188037
Chattanooga, TN 37422-8037

For Dental DHMO Plans, print PDF form and send to:
Cigna Healthcare Dental - Reimbursement
P.O. Box 188045
Chattanooga, TN 37422-8045

Regardless of which option you choose, please note that it can take up to 60 days for a reimbursement form to be processed, and this benefit does not apply to all plans. Review your Evidence of Coverage (EOC) for benefit details.

Medical Payment Appeal Form

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.

HealthSpring Medicare Advantage Member and Representative Claim Appeal Form [PDF]

Last Updated 10/01/2025

Print PDF form and send to:
HealthSpring Medicare
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37422

Fax:

Need more information?

Call: (TTY 711)

October 1 – March 31: 8 a.m. – 8 p.m., local time, 7 days a week

April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday (messaging service used weekends, after hours and federal holidays)

Medical Pre-Service Appeal Form

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.

HealthSpring Medicare Advantage Member and Representative Authorization Appeal Form [PDF]

Last Updated 10/01/2025

Print PDF form and send to:
HealthSpring
Attn: Appeals
P.O. Box 188081
Chattanooga, TN 37422

Fax:

Need more information?

Call: (TTY 711)

October 1 – March 31: 8 a.m. – 8 p.m., local time, 7 days a week

April 1 – September 30: 8 a.m. – 8 p.m., Monday – Friday (messaging service used weekends, after hours and federal holidays)

Medical Reimbursement Claim Form*

Medicare Advantage Plans

Medical Reimbursement Claim Form [PDF]

Last Updated 10/01/2025

Print PDF form and send to:

HealthSpring
Attn: Claims
P.O. Box 104
Nashville, TN 37202

Medicare Prescription Payment Plan Request Forms*

Use this form to opt-in for the Medicare Prescription Payment Plan. Once you’ve completed the form, mail it to the address below. Please note that this voluntary program only applies to Part D Prescription Drug Plans and Medicare Advantage Plans with Part D (MAPD).

Medicare Prescription Payment Plan Request Form [PDF]

Online Form

Last Updated 10/01/2025

If not using online form, print PDF form and send to:
Express Scripts MPPP
P.O. Box 801101
Kansas City, MO 64180-1101

Prescription Drug Claim (Reimbursement) Form
Use when you want to get reimbursed for a medication that you have already paid for.

Prescription Drug Claim Form [PDF]

Last Updated 12/18/2025

Print Prescription Drug Claim Form PDF and send to:
Express Scripts
Attn: Medicare Part D
P.O. Box 52023
Phoenix, AZ 85072

Fax: 1-608-741-5483

Redetermination Request Form
Use when you want us to re-review coverage of a medication or a payment/reimbursement request after it has been denied.

Redetermination Request Form [PDF]

Last Updated 12/18/2025

Print Redetermination Request Form PDF and send to:
Express Scripts
Attn: HealthSpring Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588

Fax: 1-866-593-4482