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Print a prescription drug claim form

Print a prescription drug claim form (Spanish)

Print and complete this form for medical, dental, vision, hearing, or vaccine reimbursement.

• Fill out this form if you were billed directly by a provider and would like to request reimbursement for medical care (includes dental, vision, hearing and vaccines). Don’t use this form for prescription drug reimbursement.

Medical, Dental, Hearing, Vision & Vaccine Reimbursement Form

Medical, Dental, Hearing, Vision & Vaccine Reimbursement Form (Spanish)

No printer?  No problem.  Learn what to send us for reimbursement.

Instructions if you can’t print the medical reimbursement form

Instructions if you can’t print the medical reimbursement form (Spanish)

Medicare Advantage Prescription Drug (MAPD) plans and Prescription Drug Plans (PDP)
 

Choose how you would like to enroll in an Aetna Medicare plan.

Dual Eligible Special Needs Plan (D-SNP)
 

If you have Medicare and Medicaid, you may qualify for a D-SNP.
 

Explore your options here
 

Medicare Supplement Insurance (Medigap) Plan
 

To enroll in a Medicare Supplement Insurance plan, please call us at ${medsupenroll} ${tty} ${medsupphours}. 

Aetna is the brand name for insurance products issued by the subsidiary insurance companies controlled by Aetna, Inc. The Medicare Supplement Insurance plans are insured by Aetna Health and Life insurance Company, Aetna Life Insurance Company, American Continental Insurance Company or Continental Life Insurance Company of Brentwood, Tennessee, all Aetna Companies. Not connected with or endorsed by the U.S. Government or the Federal Medicare Program.

Let someone else talk to us about your health or coverage

• One-time only: You can give us your permission by phone. We can speak with that person during that call.
• On an ongoing basis: You may want someone to speak with us more often. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. It lets this person access your personal health information. They can also speak with us on your behalf.

Open and print the PHI form

Open and print the PHI form (Spanish)

Let someone file a grievance (complaint), ask for coverage or make an appeal for you

• You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form.
• Fill out this form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Aetna Medicare and go to the CMS website if you link to the form.

Appointment of Representative CMS Form

Appointment of Representative CMS Form (Spanish)

Medication Order Form for CVS Caremark^® Mail Service Pharmacy

Medication Order Form for CVS Caremark Mail Service Pharmacy (Spanish)

Medication Action Plan

Medication Action Plan (Spanish)

Personal Medication List

Personal Medication List (Spanish)

Learn more about requesting an exception or filing a grievance or appeal:

Access forms and learn what steps to take

There are four ways to voluntarily disenroll from a Medicare Part D prescription drug plan (PDP):

1. Enroll in another Medicare plan

If you are already enrolled in a Medicare prescription drug plan (PDP), you will be disenrolled if you enroll in another Medicare prescription drug plan (PDP) or Medicare Advantage plan that includes prescription coverage (MAPD). You can choose another plan during the Annual Enrollment Period (October 15 through December 7 annually) or during a Special Enrollment Period (SEP) allowed by Medicare.

2. By mail or fax
You can send us a letter with your plan information, or you can download and complete your plan’s form:

SilverScript Smart Rx (PDP) Disenrollment Form

SilverScript Smart Rx (PDP) Disenrollment Form – Spanish

SilverScript Choice (PDP) Disenrollment Form

SilverScript Choice (PDP) Disenrollment Form – Spanish

SilverScript Plus (PDP) Disenrollment Form

SilverScript Plus (PDP) Disenrollment Form – Spanish

Complete, sign and mail or fax the form to:

SilverScript Insurance Company
P.O. Box 30007
Pittsburgh, PA 15222-0330
Fax: 1-866-552-6205

3. Call the Member Services number on your member ID card and request a disenrollment form

You can call us 24 hours a day, 7 days a week, to let us know of your intention to disenroll. The representative will send you a form you’ll need to complete. We can’t disenroll you without this form. Once we receive your completed form, we’ll send you a letter informing you of the date your coverage ends.

4. Call Medicare and tell them you want to disenroll

You can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users, please call 1-877-486-2048. The representative will work with you to process your disenrollment.

While you’re waiting for your enrollment to end, you’re still a member of our plan. To use your prescription drug benefits, you must continue to use one of our network pharmacies and follow the plan rules until you’re officially disenrolled.

Note: If you do not receive a letter from us informing you of your disenrollment date, call the Member Services number on your member ID card. The representative can tell you the date your coverage will end.