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Materials and forms

Get the most out of your Aetna Assure Premier Plus (HMO D-SNP) plan with these member materials and forms.

Member materials

2025 Annual Notice of Change — English (PDF) | Español (PDF)

2025 Evidence of Coverage — English (PDF) | Español (PDF)

2025 Summary of Benefits — English (PDF) | Español (PDF)

2025 Enrollment form — English (PDF) | Español (PDF)

Privacy notice — English (PDF) | Español (PDF)

Helpful links

2025 Prescription Drug Search tool

2025 Pharmacy locator search tool

Advance directives

Independent Utilization Review Organizations (IURO)

Printable forms

Prior authorization-related forms

Medical Prior authorization form (PDF)

Hospice exception form (PDF)

Part D Coverage determination form — English (PDF) | Spanish (PDF)

Pharmacy- and prescription-related forms

Sample personal medication list — English (PDF) | Español (PDF)

Sample recommendation to do list — English (PDF) | Español (PDF)

Complaint- and appeal-related forms

Appointment of representative (PDF)

Part D coverage redetermination form — English (PDF) | Spanish (PDF)

Information- and privacy-related forms

Authorization to release protected health information (PDF)

Request for an accounting of disclosures of protected health information (PDF)

Wig Member Reimbursement Form (PDF)

Member Appointment Assistance Form (PDF)

Interactive forms

Complaints and appeals

File a complaint or appeal online.
Fraud, waste and abuse

Report suspected cases of fraud, waste and abuse online.
Request coverage

Use this form to request drug coverage.
Coverage redetermination

You can ask for an appeal if we denied your request for coverage, or payment, for a drug. An appeal can be made within 65 days of getting your Notice of Denial of Medicare Prescription Drug Coverage letter.
Contact us

You can send us a message here.

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