Skip to main content

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

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


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


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


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


2024 Privacy notice — 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)

Interactive forms

Also of interest: