To submit a claim for reimbursement, please download, complete and submit the forms below. You will find submission instructions and when you can expect to receive reimbursement within each form.
No printer? No problem. Here’s what to send us for reimbursement.
To request coverage for a medical service or prescription drug, you must follow a few steps. For example, the process to request a coverage decision for medical services can be different than the process for prescription drugs. We’ve put together a framework to help you find the right process for yourrequest.
An appeal is a formal way of asking us to review and change a coverage decision we made. The appeals process can differ depending on what type of medical service you’re trying to appeal. You can learn more about how to appeal a coverage decision for medical coverage or prescription drugs at our appeals and grievances center.
The Medicare Extra Help program is for those with limited income and resources. Extra Help from Medicare can help you pay for your prescriptions if you qualify.
If you’re moving to a new address or getting a new phone number, please let us know right away. Just call Member Services at the number on your ID card. Based on where you move, you may need to enroll in a new plan.
If you get Medicare coverage through an employer, union or retiree plan, you may need to contact your benefits administrator to update your address or phone number.
If you need a new, duplicate or additional ID card, you can view and print one within your secure member website. A digital or printed card is identical to a plastic ID card. If you’re unable to log in or do not have an account, please call Member Services to log in or replace a lost card.
You may enroll in a new Aetna Medicare plan. To avoid a gap in your coverage, please enroll before December 31, 2019.*
Starting October 15, you can enroll in your new Aetna plan through the following ways:
If you have any questions about termination, discontinued coverage, benefits or other Medicare information, please call Member Services at 1-833-254-7659 (TTY: 711).
*This may not apply to members receiving Extra Help.
There are two main time periods when you can change or leave your Medicare Advantage (Part C) or prescription drug (Part D) plan.1
During Medicare's annual election period: 10/15 – 12/7
From October 15 through December 7 each year, you can decide to keep your current plan or select a new plan. Your coverage will begin on January 1 of the following year, if we get your request during the annual election period.
Medicare beneficiaries may also enroll in an Aetna Medicare plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
During a special enrollment period granted to you for certain situations
In certain situations, you can change your Medicare plan outside of Medicare’s annual election period. Some examples include if you:
If you get coverage from an employer or group health plan, review the information they provided to see what options are available to you.
Generally, your membership on your current plan will end on the last day of the month after we get your request to switch to Original Medicare or another 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. We’ll let you know your options. Like joining a plan, there are only certain times when you can disenroll.2 You may also download, complete and submit a disenrollment form below:
Select your plan below to print a disenrollment form:
Please complete the relevant form and mail it to:
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.
Some Aetna plans have a home delivery option through the CVS Caremark® Mail Service Pharmacy. To get started with home delivery, please visit the CVS Caremark® Mail Service Pharmacy page.
If you need help just once, you can give us your permission by phone. We can speak with that person during the call.
If you want to appoint someone to act as a long-term care manager or authorized representative, 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 about benefits, coverage, claims, bills and more.
Return the completed form to us at the address or fax number shown on the form.
It’s important to know:
The PHI form doesn’t override Medicare Power of Attorney documents. You don’t need to complete the PHI form if you have a Power of Attorney (POA).
The PHI form is only good for one year. You need to complete a new form each year for a representative to continue to assist you.
You need to complete a separate form (see below), if you need help filing an initial request for coverage, a grievance or an appeal.
You have a few options when filing a complaint. You can:
We’ll get back to you within 30 days (24 hours if you request a faster response). To send a complaint to Medicare, complete the Medicare Electronic Complaint form.
You can select or change your PCP online through the secure member site. Or you can call us at the number on your ID card. You may need to choose your PCP from your plan’s network.
1 There may be other times when you can join or leave a plan. See Medicare’s full list of special situations.
2 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.
Aetna Medicare is a HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.
A Member Services agent can help you get answers.
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