Medicare Form

2012 Enrollment Forms

• 2012 Aetna Medicare Plans (HMO) (PPO) Enrollment Form - Y0001_M_PE_FM_10807 CMS Approved 09/12/2011 (Instructions) and Y0001_M_PE_FM_10806_R1 CMS Approved 09/08/2011 (Form) (5 pages, 420kb)
• 2012 Aetna Medicare Rx Plans (PDP) Enrollment Form S5810_D_PE_FM_10805 CMS Approved 09/09/2011 (Instructions) and S5810_D_PE_FM_10804 CMS Approved 09/09/2011 (Form) (5 pages, 425kb)

2012 Plan Change Forms

• 2012 Aetna Medicare Advantage Plan Change Form (HMO, PPO) - Y0001_M_PE_FM_10809 CMS Approved 09/12/2011 (Instructions) and Y0001_M_PE_FM_10808_R1 CMS Approved 11/07/2011 (Form) (4 pages, 328kb)
• 2012 Aetna Medicare Rx Plans (PDP) Change Form - S5810_D_PE_FM_10803 CMS Approved 09/09/2011 (Instructions) and S5810_D_PE_FM_10802 CMS Approved 08/30/2011 (Form) (4 pages, 321kb)

Pharmacy Directories

(English and Spanish combined)

Our pharmacy network includes over 65,000 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_R1 CMS Approved 12/29/2011 (2 pages, 227kb)

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 GR-68775 (5-12) (2 pages, 348 KB)

Exception, Appeals and Grievances Forms

• Request for Prescription Drug Coverage Determination PDF Form Y0001_M_AP_FM_11146 CMS File & Use 12/08/2011 (3 pages, 277 KB)
• CMS Request for Prescription Drug Coverage Determination Online Form
• 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 PDF Form Y0001_M_AG_FM_10121 File & Use 02/15/2011 (2 pages, 273 kb)
• CMS Appointment of Representative Online Form
• 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 2012 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 2012

• Listado de medicamentos cubiertos - Y0001_M_PE_MM_11241 CMS Approved 11/22/2011 (44 pages, 3,600kb)
• Transición de la Carta de Cobertura - Y0001_M_AP_LT_11130 CMS Approved 10/13/2011 (6 pages, 112 kb)

Inscripción individual 2012

• 2012 Aetna Medicare Plans (HMO) (PPO) Spanish Enrollment Form - Y0001_M_PE_FM_10822 CMS Approved 09/12/2011 (Instructions) and Y0001_M_PE_FM_10823_R1 CMS Approved 11/14/2011 (Form) (5 pages, 439kb)
• 2012 Aetna Medicare Rx Plans (PDP) Spanish Enrollment Form - S5810_D_PE_FM_10824 CMS Approved 09/09/2011 (Instructions) and S5810_D_PE_FM_10825 CMS Approved 09/09/2011 (Form) (5 pages, 411kb)

Información importante para el consumidor 2012

• Determinacionesde cobertura, apelaciones y quejas formales de Medicare Advantage - Y0001_M_PE_MM_10956 CMS Approved 09/12/2011 (18 pages, 126 kb)
• Determinaciones de cobertura de medicamentos recetados, excepciones, apelaciones y quejas formales de Medicare - S5810_D_PE_MM_10957 CMS Approved 09/12/2011 (10 pages, 106 kb)

Directorios de Proveedor y Farmacia 2012 (doctores, hospitales, farmacias, etc)

• CMS NOMBRAMIENTO DE REPRESENTANTE - Y0001 M AG MM 10958 CMS File & Use 10/16/2011 (2 pages, 45 KB)