Medicare Form

2009 Enrollment Forms

• 2009 Aetna Medicare Advantage Enrollment Form (HMO, PPO, SNP) (6 pages, 236kb)
• 2009 Aetna Medicare Open^SM Plan Enrollment Form (PFFS) (6 pages, 222kb)
• 2009 Aetna Medicare Rx^® Enrollment Form (6 pages, 224kb)
• 2009 Aetna Medicare Rx^® — Costco Plus Plan Enrollment form (6 pages)

2009 Plan Change Forms

• 2009 Aetna Medicare Advantage Plan Change Form (HMO, PPO, SNP, and PFFS) (6 pages, 224kb)
• 2009 Aetna Medicare Rx Plan Change Form (6 pages, 224kb)

Claim Forms

• Medicare Prescription Drug Claim Form (2 pages, 292kb)

Timely Filing of 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. However, if you go to an out-of-network pharmacy and attempt to use your membership card, the pharmacy may not be able to submit the claim directly to us. When that happens, you'll have to pay the full cost of your prescription. Aetna will accept paper claim submissions from your date of service, until three months after the end of the plan year.  If you submit a claim for reimbursement after this timeframe, the claim will be denied for untimely filing.

For example: For the contract year ending December 31, 2009, you will have until March 31, 2010, to submit your paper claims for reimbursement.

PDP Directories

Provider Directories

Provider participation may change without notice.

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.

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.

• Aetna Quick Charge Program (2 pages, 80k)

Exception, Appeals and Grievances Forms

• Aetna Medicare Plans Complaint and Appeal Form (5 pages, 63kb)
• CMS Appointment of Representative Form (2 pages, 71kb)
• Aetna Medical Exception/Precertification Request Form for Prescription Medication (2 pages, 293kb)
• CMS Medicare Part D Coverage Determination Form (1 pages, 144kb)

Leaving a Plan

• Guide to Leaving a Plan (2 pages, 120kb)

Group plan members can view the Aetna Medicare Rx and Aetna Medicare Advantage Plans' Evidence of Coverage through Aetna Navigator (see below for instructions).

AETNA NAVIGATOR^® INSTRUCTIONS:

To view your 2009 Aetna Medicare Advantage 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

Timely Filing of 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. However, if you go to an out-of-network pharmacy and attempt to use your membership card, the pharmacy may not be able to submit the claim directly to us. When that happens, you'll have to pay the full cost of your prescription. Aetna will accept paper claim submissions from your date of service, until three months after the end of the plan year.  If you submit a claim for reimbursement after this timeframe, the claim will be denied for untimely filing.

For example: For the contract year ending December 31, 2009, you will have until March 31, 2010, to submit your paper claims for reimbursement.

Plans are offered by Aetna Health, Inc., Aetna Health of California Inc., Aetna Health of Illinois Inc., and/or Aetna Life Insurance Company. Coverage is provided through a Medicare Advantage organization or a Medicare prescription drug plan sponsor with a Medicare contract. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year.