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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. PDF Icon

Summary of Benefits

Offers detailed information about the plans available in your area, benefits, prescription drug coverage, and costs

Choose a state and a county from the lists below.



Benefits at a Glance

An easy-to-understand chart, with an overview allowing you to compare plans

Choose a state and a county from the lists below.


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Aetna Medicare Basic Plan (HMO) and Standard Plan (HMO) will not be serving the following areas effective January 1, 2012. You may choose to enroll in our plan, but your coverage will automatically end on December 31, 2011 in Lackawanna and Luzerne counties in Pennsylvania. Because this plan ends on December 31, 2011, if you decide to join, you are entitled to enroll in a new MA plan or PDP beginning December 8, 2011 through February 29, 2012. However, if you want your enrollment in the new plan to take effect on January 1, 2012, the new plan must receive your application by December 31st. You may also have the option of enrolling in a Medicare Cost Plan, if one is offered in your area. If you do not enroll in another MA plan, Medicare Cost Plan or PDP plan by December 31, 2011, you will be disenrolled from our plan and enrolled in Original Medicare on this date. You will receive additional information in the fall about your rights and additional options.

Aetna Medicare Basic Plan (HMO) will not be renewing its Medicare contract effective January 1, 2012. You may choose to enroll in our plan, but your coverage will automatically end on December 31, 2011 in Atlantic, Burlington, Camden, Cumberland, Gloucester, and Salem counties in New Jersey. Because this plan ends on December 31, 2011, if you decide to join, you are entitled to enroll in a new MA plan or PDP beginning December 8, 2011 through February 29, 2012. However, if you want your enrollment in the new plan to take effect on January 1, 2012, the new plan must receive your application by December 31st. You may also have the option of enrolling in a Medicare Cost Plan, if one is offered in your area. If you do not enroll in another MA plan, Medicare Cost Plan or PDP plan by December 31, 2011, you will be disenrolled from our plan and enrolled in Original Medicare on this date. You will receive additional information in the fall about your rights and additional options.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. A Medicare Advantage organization with a Medicare contract. A Medicare approved Part D sponsor. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2012. Plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change each year.

You may enroll in the plan only during specific times of the year. Contact Aetna Medicare for more information. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage.

You must be entitled to Medicare Part A and Part B. You must continue to pay your Part B premium and Part A, if applicable.

Alternate format materials are available by contacting Aetna Medicare at 1-888-247-1028, Monday through Sunday, 8 a.m. to 8 p.m.

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Page Last Updated: March 15, 2012