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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)

 

2024 Annual Notice of Change — English (PDF) | Español (PDF)

 

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

 

2024 Evidence of Coverage — English (PDF) | Español (PDF)

 

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

 

2024 Summary of Benefits — English (PDF) | Español (PDF)

 

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

 

2024 Enrollment form — English (PDF) | Español (PDF)

 

2025 Privacy notice — English (PDF) | Español (PDF)

 

2024 Privacy notice — English (PDF) | Español (PDF)

 

2025 OTC Catalog — English (PDF) | Español (PDF)

 

2023 OTC Catalog — English (PDF)Español (PDF)

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

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