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Forms

Need a Medicare form? You can find our most commonly used forms in this page. If you can’t find what you need, just call Member Services. They’ll be happy to help.

Find Medicare forms

 

See below for helpful resources for managing your plan and how to get started with common requests.

Claims and Reimbursements

Get paid back for prescriptions

 

If you were billed by a pharmacy for a prescription drug, you can request to be reimbursed. To do so, just mail us your completed Medicare Prescription Drug Claim form.

Get money back for paying provider bills

 

If you were billed by a medical, dental, vision or vaccine provider, you can request to be reimbursed. To do so, just send us your completed Medical Claim Reimbursement form.

No printer? Learn what to send us for reimbursement

Claims and Reimbursements

Get paid back for prescriptions

 

If you were billed by a pharmacy for a prescription drug, you can request to be reimbursed. To do so, just mail us your completed Medicare Prescription Drug Claim form.

Claims and Reimbursements

Get money back for paying provider bills

 

If you were billed by a medical, dental, vision or vaccine provider, you can request to be reimbursed. To do so, just send us your completed Medical Claim Reimbursement form.

Claims and Reimbursements

No printer? Learn what to send us for reimbursement

Give someone permission to help manage your care

Let someone else talk to us about your health or coverage

 

Call us with a caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often.

Let someone make requests for you

 

Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them sign your completed Appointment of Representative form. Once we have your form, they’ll have permission for 1 year. They can then sign and return to us complaint, coverage and appeal requests.

Give someone permission to help manage your care

Let someone else talk to us about your health or coverage

 

Call us with a caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often.

Give someone permission to help manage your care

Let someone make requests for you

 

Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them sign your completed Appointment of Representative form. Once we have your form, they’ll have permission for 1 year. They can then sign and return to us complaint, coverage and appeal requests.

Prescription drugs

Medication Order Form for CVS Caremark® Mail Service Pharmacy

 

Medication Action Plan

 

Personal Medication List

Prescription drugs

Medication Order Form for CVS Caremark® Mail Service Pharmacy

 

Medication Action Plan

 

Personal Medication List

Exceptions, appeals and grievances

Complaints and coverage requests

 

We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card. Or use the link below to learn more about your rights.

 

See how to get started

Exceptions, appeals and grievances

Complaints and coverage requests

 

We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card. Or use the link below to learn more about your rights.

 

See how to get started

Leaving a Medicare plan

Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD)

 

Call us at the number on your ID card if you want to leave your current plan and not join another one. We'll let you know if you're able to leave your plan. There are only certain times when you can disenroll.

 

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.*

 

Only 10 days until the end of the month?

 

Fax the form to: 1-866-756-5514

 

Or you can mail the form to:

 

Allina Health | Aetna Medicare

P.O Box 7405

London, KY 40702

 

*If you don’t have a creditable prescription drug coverage for 63 days or more, you may have to pay a late enrollment penalty. For example, creditable prescription drug coverage from an employer or union that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Leaving a Medicare plan

Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD)

 

Call us at the number on your ID card if you want to leave your current plan and not join another one. We'll let you know if you're able to leave your plan. There are only certain times when you can disenroll.

 

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.*

 

Only 10 days until the end of the month?

 

Fax the form to: 1-866-756-5514

 

Or you can mail the form to:

 

Allina Health | Aetna Medicare

P.O Box 7405

London, KY 40702

 

*If you don’t have a creditable prescription drug coverage for 63 days or more, you may have to pay a late enrollment penalty. For example, creditable prescription drug coverage from an employer or union that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

Patients of Veterans Affairs (VA) medical centers

Complaints and coverage requests

 

If you receive care at a VA center, privacy laws mean you must let the VA know that it’s OK to share your treatment information with us. Please fill out and return this form.

 

Mail to:

Angie England

9401 Indian Creek Parkway

Suite 3100

Overland Park, KS 66210

Patients of Veterans Affairs (VA) medical centers

Complaints and coverage requests

 

If you receive care at a VA center, privacy laws mean you must let the VA know that it’s OK to share your treatment information with us. Please fill out and return this form.

 

Mail to:

Angie England

9401 Indian Creek Parkway

Suite 3100

Overland Park, KS 66210

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Contact Member Services

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