Find forms for your Aetna® Medicare plan

For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine

Did you pay out of pocket for covered prescriptions or the vaccines listed below?

• Shingles
• Tetanus
• RSV
• Hepatitis

Just download the prescription drug claim form. Then, follow the steps in the form to fill it out and send it back to us.

Prescription drug claim form

For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine
 

Did you pay out of pocket for anything listed below?
 

• Medical, dental or vision services
• Wigs
• The flu, pneumonia or COVID-19 vaccine

Aetna Medicare members

Don’t want to file a claim online? Use the Medicare reimbursement claim form.

No longer an Aetna Medicare member?

You can still file a claim. Just download the reimbursement claim form. Then, follow the steps in the form to fill it out and send it back to us.

Medicare reimbursement claim form

For eligible fitness services or items

Did you pay for any covered fitness services or items out of pocket?

Aetna Medicare members

Don’t want to file a claim online? Use the fitness reimbursement claim form.

No longer an Aetna Medicare member? 

You can still file a claim. Just download the fitness reimbursement form. Then, follow the steps in the form to fill it out and send it back to us.  

Fitness reimbursement form

Let someone talk to us about your health or coverage

You can always call us. But sometimes, you might want a family member, personal caregiver or someone else to talk to us for you. Just fill out the PHI form and they can speak to us anytime about your care.

Aetna Medicare members

Don’t want to request online? Use the PHI form.

No longer an Aetna Medicare member?

Just download the PHI form. Then, follow the steps in the form to fill it out and send it back to us.  

Protected health information form

Let someone make requests for you

You can give a family member, personal caregiver or someone else permission to speak to us for you. They will be able to do things like: 
 

• Get a coverage decision from us to see if we'll pay for a medication or a visit to your doctor or another provider.
• File an appeal so we can review and maybe change a coverage decision we made.
• File a grievance (complaint) about your doctor, a pharmacy or something else.

If you want to have someone help with your Medicare questions, here's what to do: 
 

• Download the appointment of representative form.
• Fill it out and choose someone to speak to us for you. This can be a family member, caregiver or someone else.
• Have them sign it.
• Send the signed form to us.

This person is now called your "appointed representative." They have your permission to speak with us. The form is good for one year from the date you both sign it.

Appointment of Representative form

Order your Rx drugs from CVS Caremark Mail Service Pharmacy

Check to see if your Rx drugs are offered through mail order. If they are, you can use this form to place an order. First, download the form. Then, follow the steps in the form to fill it out and send it back to us.

Choose form language (PDF)

Do you have a concern about your coverage or care? Our Member Services team is here to help. You can call us at the number on your Aetna member ID card.