Forms

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.

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

Allina Health | Aetna Medicare members
 

Log in to file a reimbursement claim online

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

No longer an Allina Health | 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.

For eligible fitness services or items

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

Allina Health | Aetna Medicare members
 

Log in to file a fitness/reimbursement claim online

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

No longer an Allina Health | 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. 

Let someone else 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.

Allina Health | Aetna Medicare members
 

Log in to request online
 

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

No longer an Allina Health | 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. 

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, personal 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.

Medication Order Form for CVS Caremark® Mail Service Pharmacy

Personal Medication List

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

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

PO Box 14088

Lexington, KY 40512