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.
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)
By phone
Enroll in an Aetna Medicare plan over the phone by calling a licensed agent at ${dynamicPhone} ${tty}, ${hours}.
By mail
Enroll in an Aetna Medicare plan by mail. Call a licensed agent at ${dynamicPhone} ${tty}, ${hours} to request your paper enrollment kit.
We offer the following enrollment forms in Chinese:
Enrollment form - CA - Alameda County - 中文
Enrollment form - CA - Los Angeles County - 中文
Enrollment form - CA - Orange County - 中文
Enrollment form - CA - San Francisco County - 中文
Enrollment form - NY - Brooklyn & Staten Island Counties - 中文
Enrollment form - NY - New York City & Queens Counties - 中文
If you have Medicare and Medicaid, you may qualify for a D-SNP.
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.
Open and print the PHI form (Spanish)
Appointment of Representative CMS Form
Learn more about requesting an exception or filing a grievance or appeal:
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 disenroll.1 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 – Spanish
Prescription Drug Plan Disenrollment Form (Change from MAPD to MA)
Prescription Drug Plan Disenrollment Form (Change from MAPD to MA) – Spanish
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.
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.
1 If you don't have creditable coverage for 63 days or more, you may have to pay a late enrollment penalty. For example, creditable coverage from an employer or union is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. You can generally keep your coverage without paying a penalty if you decide to enroll in Medicare prescription drug coverage later.
The prescription drug forms on this page are for 2019 Aetna Medicare PDP Plans.
For 2020 Prescription Drug plan forms, please visit SilverScript.
The prescription drug forms on this page are for 2019 Aetna Medicare PDP Plans.
For 2020 Prescription Drug plan forms, please visit SilverScript.
Aetna handles premium payments through InstaMed, a trusted payment service. Your InstaMed log-in may be different from your Caremark.com secure member site log-in.
Aetna handles premium payments through Payer Express, a trusted payment service. Your Payer Express log-in may be different from your Aetna secure member site log-in.
The information you will be accessing is provided by another organization or vendor. If you do not intend to leave our site, close this message.
You are leaving our Medicare website and going to our non-Medicare website. If you do not intend to leave our site, close this message.
We’re bringing you to our trusted partner to help process your payments. This site has its own login. It may be different from your Aetna secure member site login.
La información a la que accederá es proporcionada por otra organización o proveedor. Si tu intención no era salir del sitio web, cierra este mensaje.
Aetna has selected Caremark as the prescription management and mail delivery service for our members. If you do not intend to leave our site, close this message.