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Claims and reimbursement (ask us to pay you back)	Choose PDF language
Get paid back for prescriptions If you were billed by a pharmacy for a covered prescription drug, mail us your completed form to request reimbursement.	English Español
Get reimbursed for paying provider bills If you were billed for covered services by a medical, dental, vision, hearing or vaccine provider, mail us your completed form to ask for reimbursement.	English Español
No printer? Learn what to send us for reimbursement	English Español

Claims and reimbursement (ask us to pay you back)	Get paid back for prescriptions If you were billed by a pharmacy for a covered prescription drug, mail us your completed form to request reimbursement.
Choose PDF language	English Español

Claims and reimbursement (ask us to pay you back)	Get reimbursed for paying provider bills If you were billed for covered services by a medical, dental, vision, hearing or vaccine provider, mail us your completed form to ask for reimbursement.
Choose PDF language	English Español

Claims and reimbursement (ask us to pay you back)	No printer? Learn what to send us for reimbursement
Choose PDF language	English Español

Give someone permission to help with your care	Choose PDF language
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.	English Español
Let someone make requests for you Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them 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 an Appointment of Representative form.	English Español

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.
Choose PDF language	English Español

Give someone permission to help with your care	Let someone make requests for you Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them 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 an Appointment of Representative form.
Choose PDF language	English Español

Order prescriptions by mail	Choose PDF language
Medication order form for CVS Caremark® Mail Service Pharmacy	English Español

Order prescriptions by mail	Medication order form for CVS Caremark® Mail Service Pharmacy
Choose PDF language	English Español

Exceptions, appeals and grievances
Complaints and coverage requests Please come to us if you have a concern about your coverage or care. Call us at the number on your member ID card, or learn more first. See how to get started

Exceptions, appeals and grievances	Complaints and coverage requests Please come to us if you have a concern about your coverage or care. Call us at the number on your member ID card, or learn more first. See how to get started

Disenrollment (leaving or canceling a plan)
Leave or cancel my 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 specific 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 disenroll¹. 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 Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) – Español Please complete the relevant form and mail it to: Aetna PO Box 14088 Lexington, KY 40512 Timing Considerations: If there are 10 days or fewer left until the end of the month, please fax the form to 1‑888‑665‑6296. If you leave us during the annual election period, your last day of coverage is usually Dec. 31. Important Note: If you change from a Medicare Advantage plan that includes prescription drug coverage to a Medicare prescription drug plan, this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.
Leave or cancel my prescription drug plan (PDP) If you want to cancel or switch your Medicare Part D plan (PDP) coverage, you should find out your options. Learn all about how and when to disenroll. Learn how to disenroll from your PDP

Disenrollment (leaving or canceling a plan)

Leave or cancel my 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 specific 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 disenroll¹. 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

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA)

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) – Español

Please complete the relevant form and mail it to:

Aetna
PO Box 14088
Lexington, KY 40512

Timing Considerations: If there are 10 days or fewer left until the end of the month, please fax the form to 1‑888‑665‑6296. If you leave us during the annual election period, your last day of coverage is usually Dec. 31.

Important Note: If you change from a Medicare Advantage plan that includes prescription drug coverage to a Medicare prescription drug plan, this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.

Leave or cancel my prescription drug plan (PDP)

If you want to cancel or switch your Medicare Part D plan (PDP) coverage, you should find out your options. Learn all about how and when to disenroll.

Learn how to disenroll from your PDP

Disenrollment (leaving or canceling a plan)

Leave or cancel my Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD) plan

Medicare Advantage Plan Disenrollment Form

Medicare Advantage Plan Disenrollment Form - Español

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA)

Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) – Español

Please complete the relevant form and mail it to:

Aetna
PO Box 14088
Lexington, KY 40512

Disenrollment (leaving or canceling a plan)	Leave or cancel my prescription drug plan (PDP) If you want to cancel or switch your Medicare Part D plan (PDP) coverage, you should find out your options. Learn all about how and when to disenroll. Learn how to disenroll from your PDP

Patients of Veterans Affairs (VA) health centers
Allow the VA to work with us to coordinate your care If you receive care at a VA center, privacy laws mean you must let the VA know that it’s OK to share your treatment information with Aetna. Please fill out and return this form so that we can better coordinate our outreach. This helps us make sure you get the care you need and don’t get unnecessary communications. Mail to: Aetna Medicare 9401 Indian Creek Parkway Suite 3100 Overland Park, KS 66210 Attn: Angie England Download the VA permission form

Patients of Veterans Affairs (VA) health centers

Allow the VA to work with us to coordinate your care

If you receive care at a VA center, privacy laws mean you must let the VA know that it’s OK to share your treatment information with Aetna. Please fill out and return this form so that we can better coordinate our outreach. This helps us make sure you get the care you need and don’t get unnecessary communications.

Mail to:

Aetna Medicare

9401 Indian Creek Parkway

Suite 3100

Overland Park, KS 66210

Attn: Angie England

Download the VA permission form