Claims and reimbursements (ask us to pay you back)
Find Medicare forms
See below for helpful resources for managing your plan and how to get started with common requests.
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Ask us to pay you back for prescriptions or the shingles, tetanus or RSV vaccine
Download this form. Then fill it out and mail it to the address on the form. |
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Ask us to pay you back for a covered provider or service bill, or the flu, pneumonia or COVID-19 vaccine
You can use the paper form or the online form if you were billed by a medical, dental or vision provider. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out of pocket.
To get paid back for covered wigs, use the paper form.
You can download the form, complete it and mail or fax it to us.
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Ask us to pay you back for eligible fitness items or services
If you paid for an eligible fitness item or service in 2024 download the 2024 form. Then fill it out and mail it to the address on your member ID card, or fax it to the number on the form. If you paid for an eligible fitness item or service in 2025, use the 2025 form and mail it to the address on the 2025 form. |
Claims and reimbursements (ask us to pay you back) |
Ask us to pay you back for prescriptions or the shingles, tetanus or RSV vaccine
Download this form. Then fill it out and mail it to the address on the form. |
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Claims and reimbursements (ask us to pay you back) |
Ask us to pay you back for a covered provider or service bill, or the flu, pneumonia or COVID-19 vaccine
You can use the paper form or the online form if you were billed by a medical, dental or vision provider. You should also use this form if you paid for the flu, pneumonia or COVID-19 vaccine out of pocket.
To get paid back for covered wigs, use the paper form.
You can download the form, complete it and mail or fax it to us.
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Claims and reimbursements (ask us to pay you back) |
Ask us to pay you back for eligible fitness items or services
If you paid for an eligible fitness item or service in 2024 download the 2024 form. Then fill it out and mail it to the address on your member ID card, or fax it to the number on the form. If you paid for an eligible fitness item or service in 2025, use the 2025 form and mail it to the address on the 2025 form. |
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Give someone permission to help manage your care |
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Let someone else talk to us about your health or coverage
Call us with a caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often. |
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Let someone make requests for you
Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them sign your completed Appointment of Representative form. Once we have your form, they’ll have permission for 1 year. They can then sign and return to us complaint, coverage and appeal requests. |
Give someone permission to help manage your care |
Let someone else talk to us about your health or coverage
Call us with a caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or, mail us a completed PHI (protected health information) form to give them permission more often. |
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Give someone permission to help manage your care |
Let someone make requests for you
Give a caregiver or another person permission to file a complaint (grievance), ask for coverage or make an appeal for you. Just have them sign your completed Appointment of Representative form. Once we have your form, they’ll have permission for 1 year. They can then sign and return to us complaint, coverage and appeal requests. |
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Prescription drugs |
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Medication Order Form for CVS Caremark® Mail Service Pharmacy |
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Medication Action Plan |
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Personal Medication List |
Prescription drugs |
Medication Order Form for CVS Caremark® Mail Service Pharmacy |
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Prescription drugs |
Medication Action Plan |
Prescription drugs |
Personal Medication List |
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Exceptions, appeals and grievances |
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Complaints and coverage requests
We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card. Or use the link below to learn more about your rights.
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Exceptions, appeals and grievances |
Complaints and coverage requests
We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card. Or use the link below to learn more about your rights.
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Leaving a Medicare plan |
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Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD)
Call us at the number on your ID card if you want to leave your current plan and not join another one. We'll let you know if you're able to leave your plan. There are only certain times when you can disenroll.*
Important Note: If you change from a Medicare Advantage plan that includes prescription drug coverage to a Medicare prescription drug plan, this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.
Only 10 days until the end of the month?
Fax the form to: 1-866-756-5514
Or you can mail the form to:
Allina Health | Aetna Medicare P.O Box 7405 London, KY 40702 |
Leaving a Medicare plan |
Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD)
Call us at the number on your ID card if you want to leave your current plan and not join another one. We'll let you know if you're able to leave your plan. There are only certain times when you can disenroll.*
Important Note: If you change from a Medicare Advantage plan that includes prescription drug coverage to a Medicare prescription drug plan, this will disenroll you from your Medicare Advantage plan. You’ll return to Original Medicare if you switch from a Medicare Advantage plan (with drug coverage) to a Medicare prescription drug plan.
Only 10 days until the end of the month?
Fax the form to: 1-866-756-5514
Or you can mail the form to:
Allina Health | Aetna Medicare P.O Box 7405 London, KY 40702 |
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*For times you can disenroll
If you don’t have a creditable prescription drug coverage for 63 days or more, you may have to pay a late enrollment penalty. For example, creditable prescription drug coverage from an employer or union that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.
Contact Member Services
Call an Allina Health | Aetna representative at ${membersPhone} ${tty}, ${membersHours}.