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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

 

You can use the paper form or the online form if you were billed by a medical, dental, vision or hearing provider. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out-of-pocket.

Complete online form

 

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

First, 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.
 

Did you pay out-of-pocket for covered dental, vision or hearing services?
 

Watch this video to learn how to request that we pay you back.

Ask us to pay you back for fitness items or services


If you paid for a fitness item or service in 2024, download the 2024 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.

If you paid for a fitness item or service in 2025, use the 2025 form and mail it to the address on the 2025 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

 

You can use the paper form or the online form if you were billed by a medical, dental, vision or hearing provider. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out-of-pocket.

Complete online form

 

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

First, 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.
 

Did you pay out-of-pocket for covered dental, vision or hearing services?
 

Watch this video to learn how to request that we pay you back.

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 in 2024, download the 2024 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.

If you paid for a fitness item or service in 2025, use the 2025 form and mail it to the address on the 2025 form. 

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Give someone permission to help with your care

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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.

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.

Give someone 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

Give someone 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.

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Order prescriptions by mail

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Medication order form for CVS Caremark® Mail Service Pharmacy

Order prescriptions by mail

Medication order form for CVS Caremark® Mail Service Pharmacy

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Exceptions, appeals and grievances

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 member ID card.

Exceptions, appeals and grievances

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 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.