Ask us to pay you back
Find Medicare forms
See below for helpful resources for managing your plan and how to get started with common requests.
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For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine
Did you pay out of pocket for covered prescriptions or the vaccines listed below?
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 |
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For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine
Did you pay out of pocket for anything listed below?
Allina Health | Aetna Medicare members
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Medicare reimbursement claim form |
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For eligible fitness services or items
Did you pay for any covered fitness services or items out of pocket?
Allina Health | Aetna Medicare members
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. |
Fitness reimbursement form |
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Ask us to pay you back |
For prescriptions – or – the shingles, tetanus, RSV or hepatitis vaccine
Did you pay out of pocket for covered prescriptions or the vaccines listed below?
Just download the prescription drug claim form. Then, follow the steps in the form to fill it out and send it back to us. |
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Prescription drug claim form |
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Ask us to pay you back |
For provider or service bills, wigs – or – the flu, pneumonia or COVID-19 vaccine
Did you pay out of pocket for anything listed below?
Allina Health | Aetna Medicare members
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Medicare reimbursement claim form |
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Ask us to pay you back |
For eligible fitness services or items
Did you pay for any covered fitness services or items out of pocket?
Allina Health | Aetna Medicare members
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. |
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Fitness reimbursement form |
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Give a personal caregiver permission to help with your care |
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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
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 (PHI) form |
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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:
If you want to have someone help with your Medicare questions, here's what to do:
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Appointment of Representative form |
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Give a personal caregiver permission to help with your care |
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
Just download the PHI form. Then, follow the steps in the form to fill it out and send it back to us. |
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Protected health information (PHI) form |
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Give a personal caregiver permission to help with your care |
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:
If you want to have someone help with your Medicare questions, here's what to do:
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Appointment of Representative form |
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Prescription drugs |
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Medication Order Form for CVS Caremark® Mail Service Pharmacy |
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Medication Action Plan |
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Personal Medication List |
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Prescription drugs |
Medication Order Form for CVS Caremark® Mail Service Pharmacy |
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Prescription drugs |
Medication Action Plan |
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Prescription drugs |
Personal Medication List |
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Exceptions, appeals and grievances |
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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.
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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.
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Leaving a Medicare plan |
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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 |
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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 PO Box 14088 Lexington, KY 40512 |
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For times you can disenroll
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.
Contact Member Services
Call an Allina Health | Aetna representative at ${membersPhone} ${tty}, ${membersHours}.
Contact Member Services
Call an Allina Health | Aetna representative at ${membersPhone} ${tty}, ${membersHours}.
Disclaimer
CVS Caremark® Mail Service Pharmacy and Aetna are part of the CVS Health® family of companies.