Claims and reimbursement (ask us to pay you back)
Find the forms you need
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Choose PDF language |
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Get paid back for prescriptions
If a pharmacy billed you for a covered prescription drug, mail us your completed form to request reimbursement. |
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Get reimbursed for paying provider or service-related bills
Enrolled in a Medicare plan for 2024? You can use this process for covered services starting on January 1, 2024.
Were you billed for covered services? You can use this form if you were billed by a medical, dental, vision, hearing, fitness, wigs or vaccine provider.
Fill out this online form to ask for reimbursement. You can also download the form in English or Spanish. Then, mail or fax the completed form to us. Complete online form |
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No printer? Learn what to send us for reimbursement
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Claims and reimbursement (ask us to pay you back) |
Get paid back for prescriptions
If a pharmacy billed you for a covered prescription drug, mail us your completed form to request reimbursement. |
|---|---|
Choose PDF language |
|
Claims and reimbursement (ask us to pay you back) |
Get reimbursed for paying provider or service-related bills
Enrolled in a Medicare plan for 2024? You can use this process for covered services starting on January 1, 2024.
Were you billed for covered services? You can use this form if you were billed by a medical, dental, vision, hearing, fitness, wigs or vaccine provider.
Fill out this online form to ask for reimbursement. You can also download the form in English or Spanish. Then, mail or fax the completed form to us. Complete online form |
Choose PDF language |
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Claims and reimbursement (ask us to pay you back) |
No printer? Learn what to send us for reimbursement
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Choose PDF language |
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Give someone permission to help with your care |
Choose PDF language |
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Let someone talk to us about your health or coverage
Call us with a caregiver or someone else on the line to give them permission to speak with us (just one time, on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often. |
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Let someone make requests for you
Give a caregiver or someone else permission to act on your behalf. They will be able to:
Just have this person sign your completed Appointment of Representative form and send it to us. This person is then your appointed representative for one year from the date that you both sign the form. |
Give someone permission to help with your care |
Let someone talk to us about your health or coverage
Call us with a caregiver or someone else on the line to give them permission to speak with us (just one time, on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often. |
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Choose PDF language |
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Give someone permission to help with your care |
Let someone make requests for you
Give a caregiver or someone else permission to act on your behalf. They will be able to:
Just have this person sign your completed Appointment of Representative form and send it to us. This person is then your appointed representative for one year from the date that you both sign the form. |
Choose PDF language |
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Exceptions, appeals and grievances |
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Complaints and coverage requests
Have a concern about your coverage or care? Our Member Services team is here to help. Just give us a call at the number on your member ID card. |
Exceptions, appeals and grievances |
Complaints and coverage requests
Have a concern about your coverage or care? Our Member Services team is here to help. Just give us a call at the number on your member ID card. |
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Disenrollment (leaving or canceling a plan) |
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Leave or cancel your Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD) plan
Call us at the number on your ID card if you want to leave or cancel your current plan and not join another one. Or select your current plan and find its phone number on our Contact Member Services page. We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll*. You may also download, complete and submit a disenrollment form — use the PDF link for your plan below to print its form: Medicare Advantage Plan Disenrollment Form Medicare Advantage Plan Disenrollment Form - Español
Please complete the relevant form and mail it to: Aetna
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Leave or cancel your prescription drug plan (PDP)
If you want to cancel or switch your Medicare Part D plan (PDP), find out what your options are. Learn all about how and when to disenroll. |
Disenrollment (leaving or canceling a plan) |
Leave or cancel your Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD) plan
Call us at the number on your ID card if you want to leave or cancel your current plan and not join another one. Or select your current plan and find its phone number on our Contact Member Services page. We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll*. You may also download, complete and submit a disenrollment form — use the PDF link for your plan below to print its form: Medicare Advantage Plan Disenrollment Form Medicare Advantage Plan Disenrollment Form - Español
Please complete the relevant form and mail it to: Aetna
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Disenrollment (leaving or canceling a plan) |
Leave or cancel your prescription drug plan (PDP)
If you want to cancel or switch your Medicare Part D plan (PDP), find out what your options are. Learn all about how and when to disenroll. |
* FOR TIMES YOU CAN DISENROLL: If you don't have creditable coverage for 63 days or more, you may have to pay a late penalty when you sign up. For example, creditable coverage from an employer or union should pay, on average, at least as much as Medicare's standard prescription plan. You can generally keep your coverage without paying a penalty if you enroll in Medicare prescription drug coverage later.