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Find forms for your Aetna® Medicare plan

Aetna® Medicare forms: claims and reimbursement, Appointment of Representative and more

 

Claims and reimbursement (ask us to pay you back)

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Ask us to pay you back for prescriptions or the shingles, tetanus or RSV vaccine

 

Download this form. Then fill it out and mail it to the address on the form.

Ask us to pay you back for provider or service bills or the flu, pneumonia or COVID-19 vaccine
 

Use this form if you paid out of pocket for a covered medical, dental or vision service. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out of pocket.

Are you a member?

Log in to file a claim

 

To get paid back for wigs, use the paper form. 

No longer an Aetna Medicare member?
You can still file a claim for covered services. Make sure to file your claim within 365 days of the date of service.
 

First, download the form in English or Spanish. Then follow the steps in the form to fill it out and send it back to us.
 

Ask us to pay you back for fitness items or services


If you paid for a fitness item or service download the form in English or Spanish. Then fill it out and mail it to the address on your Aetna member ID card, or fax it to the number on the form.

Claims and reimbursement (ask us to pay you back)

Ask us to pay you back for prescriptions or the shingles, tetanus or RSV vaccine

 

Download this form. Then fill it out and mail it to the address on the form.

Choose PDF language

Claims and reimbursement (ask us to pay you back)

Ask us to pay you back for provider or service bills or the flu, pneumonia or COVID-19 vaccine
 

Use this form if you paid out of pocket for a covered medical, dental or vision service. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out of pocket.

Are you a member?

Log in to file a claim

 

To get paid back for wigs, use the paper form. 

No longer an Aetna Medicare member?
You can still file a claim for covered services. Make sure to file your claim within 365 days of the date of service.
 

First, download the form in English or Spanish. Then follow the steps in the form to fill it out and send it back to us.
 

Choose PDF language

Claims and reimbursement (ask us to pay you back)

Ask us to pay you back for fitness items or services


If you paid for a fitness item or service download the form in English or Spanish. Then fill it out and mail it to the address on your Aetna member ID card, or fax it to the number on the form.

Choose PDF language

Forms to give a caregiver 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.

Protected health information forms

 

Let someone make requests for you

 

Give a caregiver or someone else permission to act on your behalf. They will be able to:

 

  • File a complaint (grievance)
  • Ask for coverage
  • Make an appeal for you

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.

Appointment of Representative forms  

 

Forms to give a caregiver 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

Protected health information forms

 

Forms to give a caregiver 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:

 

  • File a complaint (grievance)
  • Ask for coverage
  • Make an appeal for you

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

Appointment of Representative forms  

 

Order prescriptions by mail

Choose PDF language

Medication order form for CVS Caremark® Mail Service Pharmacy

Order prescriptions by mail

Medication order form for CVS Caremark® Mail Service Pharmacy

Choose PDF language

Exceptions, appeals and grievances

File Medicare 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 Aetna member ID card.

Exceptions, appeals and grievances

File Medicare 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 Aetna member ID card.

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.

 

 

Please complete the relevant form and mail it to:

Aetna
PO Box 7405
London, KY 40742


Timing Considerations: If there are 10 days or fewer left until the end of the month, please fax the form to 1-866-756-5514. If you leave the plan during the annual election period, your last day of coverage is usually December 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 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.

 

 

Please complete the relevant form and mail it to:

Aetna
PO Box 7405
London, KY 40742


Timing Considerations: If there are 10 days or fewer left until the end of the month, please fax the form to 1-866-756-5514. If you leave the plan during the annual election period, your last day of coverage is usually December 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.

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.