Medicare Form
Download Documents: 2011
Find the documents and forms you need for Aetna Medicare individual plans here.
Looking for documents such as enrollment and claim forms, as well as the Summary of Benefits for plans available near you? First, select the tab for the type of document you wish to view. The following documents are provided as Adobe PDF files. 
2011 Enrollment Forms
- 2011 Aetna Medicare Plans (HMO) (PPO) Enrollment Form - Y0001_M_PE_FM_008138 CMS Approved 09/23/2010 (Instructions) and Y0001_M_PE_FM_008133 CMS Approved 09/14/2010 (Form) (5 pages, 419kb)
- 2011 Aetna Medicare Rx Plans (PDP) Enrollment Form S5810_D_PE_FM_008140 CMS Approved 09/23/2010 (Instructions) and S5810_D_PE_FM_008135 CMS Approved 09/09/2010 (Form) (5 pages, 405kb)
2011 Plan Change Forms
- 2011 Aetna Medicare Advantage Plan Change Form (HMO, PPO) - Y0001_M_PE_FM_008139 CMS Approved 09/23/2010 (Instructions) and Y0001_M_PE_FM_008134 CMS Approved 09/14/2010 (Form) (4 pages, 317kb)
- 2011 Aetna Medicare Rx Plans (PDP) Change Form - S5810_D_PE_FM_008141 CMS Approved 09/22/2010 (Instructions) and S5810_D_PE_FM_008136 CMS Approved 09/09/2010 (Form) (4 pages, 321kb)
Pharmacy Directories
(English and Spanish combined)
Our pharmacy network includes over 60,000 pharmacies.
Choose a state from the drop down below to find pharmacies in your area.
Provider participation may change without notice. Please visit DocFind for the most up-to-date in either Medical Providers or Pharmacy from the "Provider Category" drop down.
Aetna Formulary
View the Aetna preferred drug list, check to see if your drugs are covered by Aetna plans, and obtain prior authorization information.
Aetna Rx Home Delivery®
Learn more about Aetna Rx Home Delivery or read a brochure:
- Aetna Medicare members can log on to Aetna Navigator. Select the "Pharmacy Benefits" tab under "Related Shortcuts."
- If you are not yet an Aetna member, get Aetna Rx Home Delivery information here.
Claim Forms
- Medicare Prescription Drug Claim Form Y0001_M_AP_FM_01144 CMS Approved 01/24/2011 (2 pages, 47kb)
Your Aetna Medicare Prescription Drug Claim
When you go to a network pharmacy and use your membership card, your claim is automatically submitted to us by the pharmacy. If you go to a network pharmacy and they are unable to submit the claim to us, you may have to pay for the full cost of the prescription and request reimbursement from Aetna. You may use the Medicare Prescription Drug Claim Form when requesting reimbursement for a pharmacy claim.
Aetna Quick Charge Program (EFT)
Authorize Aetna to automatically withdraw your plan premium from your bank account, or charge the premium to your credit card, on the date it is due. Please place a copy of the form in an envelope and mail it to the address on the form.
- Aetna Quick Charge Program Y0001_M_PE_FM_00206 (2 pages, 1,018kb)
Exception, Appeals and Grievances Forms
- Request for Prescription Drug Coverage Determination Form Y0001_M_AP_FM_11146 CMS File & Use 12/08/2011 (3 pages, 277 KB)
- Request for Redetermination of an Aetna Medicare Prescription Drug Denial (Appeal) Y0001_M_AG_FM_11152 CMS Approved 12/12/2011 (2 pages, 168 KB)
- Request for an Appeal of an Aetna Medicare Advantage Plan Denial Y0001_M_AG_FM_11151 CMS Approved 12/08/11 (2 pages, 165 KB)
- Aetna Medicare Grievance Form Y0001_M_AG_FM_11150 CMS Approved 12/14/2011 (2 pages, 166kb)
- CMS Appointment of Representative Form Y0001_M_AG_FM_10121 File & Use 02/15/2011 (2 pages, 273 kb)
- Provider Waiver of Liability Y0001_M_AG_FM_10122 File & Use 01/29/2011 (1 page, 16kb)
Group plan members can view the Aetna Medicare Rx Plan (PDP) and Aetna Medicare Advantage Plan (HMO, PPO) Evidence of Coverage through Aetna Navigator (see below for instructions).
AETNA NAVIGATOR® INSTRUCTIONS:
To view your 2011 Aetna Medicare Plan Evidence of Coverage, please log in to Aetna Navigator, our secure member website:
- Select the "Benefits" menu,
- Choose "Details," and
- Open the "Member Plan Documents" PDF
Spanish Documents
Listado de medicamentos 2011
- Listado de medicamentos cubiertos - Y0001_M_PE_MM_009176 CMS Approved 10/27/2010 (35 pages, 2,320kb)
Brochures 2011
- 2011 Aetna Medicare Rx Plan (PDP) - S5810_D_PE_MM_009174 CMS Approved 10/26/2010 (5 pages, 2,937kb)
- 2011 Aetna Medicare Rx-Costco Plus Plan (PDP) - S5810_D_PE_MM_009175 CMS Approved 10/26/2010 (5 pages, 1,213kb)
- 2011 Aetna Medicare Plan (HMO/PPO) - Y0001_M_PE_MM_009173 CMS Approved 10/27/2010 (5 pages, 2,790kb)
Inscripción individual 2011
- 2011 Aetna Medicare Plans (HMO) (PPO) Spanish Enrollment Form - Y0001_M_PE_FM_009165 CMS Approved 9/30/2010 (Instructions) and Y0001_M_PE_FM_009167 CMS Approved 9/30/2010 (Form) (5 pages, 427kb)
- 2011 Aetna Medicare Rx Plans (PDP) Spanish Enrollment Form - S5810_D_PE_FM_009164 CMS Approved 9/30/2010 (Instructions) and S5810_D_PE_FM_009166 CMS Approved 9/30/2010 (Form) (5 pages, 410kb)
Información importante para el consumidor 2011
- 2011 Aetna Medicare Plan (HMO)(PPO) - Y0001_M_PE_MM_009177 CMS Approved 10/27/2010 (19 pages, 1,800kb)
- 2011 Aetna Medicare Rx (PDP) - S5810_D_PE_MM_009178 CMS Approved 10/26/2010 (12 pages, 1,300kb)
Directorios de Proveedor y Farmacia 2011 (doctores, hospitales, farmacias, etc)
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