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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)


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 (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