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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

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


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

 

Journey Handbook — English (PDF) | Español (PDF)

Printable forms

 

Prior authorization-related forms

 

Medical Prior authorization form (PDF)


Hospice exception form (PDF)


Part D Coverage determination form (PDF)

 

 

Pharmacy- and prescription-related forms

 

Prescription mail service order form — English (PDF) | Español (PDF)


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


Sample personal medication action plan — English (PDF) | Español (PDF)

 

 

Complaint- and appeal-related forms

 

Appointment of representative (PDF)


Part D Coverage redetermination form (PDF)

 

 

Information- and privacy-related forms


Authorization to release protected health information (PDF)


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


Authorization to release psychotherapy notes (PDF)

Interactive forms