Plan benefits and forms

Medicare plans have many different details and forms, so we’ve organized everything together into one convenient place.

Your Aetna plan benefits and forms

Knowing more about your plan can help you get the most from your benefits and covered services. Find your plan’s Summary of Benefits, Formulary (list of covered drugs) and other coverage details below. Your member ID card shows your plan’s name. See a word or term you don't know? Check our glossary.
 

CHOOSE YOUR PLAN YEAR:

2022
 

Aetna Medicare (HMO) for College Insurance Program (CIP)

Evidence of Coverage (EOC) – (HMO with Rx) - English (PDF) 

Summary of Benefits – (MAPD CIP Plan) - English (PDF) 

Annual Notice of Change (ANOC) – (MAPD CIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD CIP Plan) - English (PDF)

 

Aetna Medicare (HMO) for State Employees Group Insurance Plan (SEGIP)

Evidence of Coverage (EOC) – (HMO SEGIP Plan) - English (PDF)

Summary of Benefits – (MAPD SEGIP Plan) - English (PDF)

Annual Notice of Change (ANOC) – (MAPD SEGIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD SEGIP Plan) - English (PDF)

 

Aetna Medicare (HMO) for Teachers’ Retiree Insurance Program (TRIP)

Evidence of Coverage – (HMO TRIP Plan) - English (PDF)

Summary of Benefits – (MAPD TRIP Plan) - English (PDF)

Annual Notice of Change (ANOC) – (MAPD TRIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD TRIP Plan) - English (PDF)

 

Star Ratings - English (PDF)

2023
 

Aetna Medicare (PPO) for College Insurance Program (CIP)

Evidence of Coverage (EOC) – (PPO with Rx) - English (PDF) 

Summary of Benefits – (MAPD CIP Plan) - English (PDF) 

Annual Notice of Change (ANOC) – (MAPD CIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD CIP Plan) - English (PDF)

Highlights Brochure - English (PDF)

Information Guide - English (PDF)

 

Aetna Medicare (PPO) for State Employees Group Insurance Plan (SEGIP)

Evidence of Coverage (EOC) – (PPO SEGIP Plan) - English (PDF)

Summary of Benefits – (MAPD SEGIP Plan) - English (PDF)

Annual Notice of Change (ANOC) – (MAPD SEGIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD SEGIP Plan) - English (PDF)

Highlights Brochure - English (PDF)

Information Guide - English (PDF)

 

Aetna Medicare (PPO) for Teachers’ Retiree Insurance Program (TRIP)

Evidence of Coverage – (PPO TRIP Plan) - English (PDF)

Summary of Benefits – (MAPD TRIP Plan) - English (PDF)

Annual Notice of Change (ANOC) – (MAPD TRIP Plan) - English (PDF)

Schedule of Cost Sharing (SOC) – (MAPD TRIP Plan) - English (PDF)

Highlights Brochure - English (PDF)

Information Guide - English (PDF)

 

Star Ratings - English (PDF)

Review your Evidence of Coverage (EOC) to learn about comprehensive plan details, and your rights and responsibilities. You can request a copy of your Evidence of Coverage if you need one.

Find Medicare forms

See below for helpful resources for managing your plan and how to get started with common requests.

File claims and reimbursement requests

If you were billed by a pharmacy for a prescription drug, mail us your completed form to request a reimbursement. 

Prescription drug claim form - English (PDF) | Español (PDF)

If you were billed directly by a provider, mail us your completed form to request reimbursement. 

Reimbursement form - English | Español
Print-free reimbursement instructions - English | Español

Printer-free reimbursement instructions - English (PDF) | Español (PDF)

Give someone permission to manage your care

Call us with your caregiver or another person on the line to give them permission to speak with us (just one time, while on that call). Or you can mail us a completed Protected Health Information (PHI) form to give them permission on a regular basis.

 

PHI form - English (PDF) | Español (PDF)

Complete these forms with your Medication Therapy Management (MTM) providers, and update them (as needed) with every doctor, pharmacist, nurse or caregiver you see. Take notes with your Medication Action Plan to remember medical advice, important things to do and questions to ask. Use your Personal Medication List to save and update your medication history.

Medication Action Plan - English (PDF) | Español (PDF)

Personal Medication List - English (PDF) | Español (PDF) 

Explore MTM resources

You can choose someone to do all of the above. This person is your appointed representative. An appointment is good for one year from the date that you and your representative sign an Appointment of Representative form. 

Fill out the form below and mail it to us. Any time your representative makes a request for you, they should send us a signed copy. You'll leave Aetna Medicare and go to the Center for Medicare and Medicaid Services (CMS) website if you link to the form. 

Appointment of Representative CMS Form - English (PDF) | Español (PDF)

Manage your medications

Complete and return this form to get your prescriptions delivered to you. 

Medication order form for CVS Caremark® Mail Service Pharmacy - English (PDF) | Español (PDF)

Learn more about Rx home delivery

 

Exceptions, appeals and grievances

We want to be your first stop when you have a concern about your coverage or care. Call us at the number on your member ID card, or learn more here.

See how to get started

Additional information

While you can find these documents online, sometimes you may need a printed version mailed to you.  

Request a printed Evidence of Coverage (EOC)

Request a printed Provider Directory  - Call us at 1-855-223-4807 (TTY: 711), Monday to Friday, 8 AM to 8 PM CT.

Request a printed formulary 

Medicare Helpline And Website - Get general or claims-specific Medicare information, request documents in alternate formats and make changes to your Medicare coverage. Call 1-800-MEDICARE (1-800-633-4227) or TTY: 1-877-486-2048, 7 days a week, 24 hours a day. If you need help in a language other than English or Spanish, say “Agent” to talk to a customer service representative. Or visit the Medicare website.

Social Security Administration - For questions about Medicare eligibility, Social Security retirement benefits or help paying for prescription drugs. Call 1-800-772-1213 or TTY: 1-800-325-0778, Monday to Friday, 8 AM to 7 PM or visit the Social Security website.

Most health care professionals and organizations that provide Medicare services are honest. Unfortunately, there may be some who are not. If you ever suspect fraud, please contact Member Services at the number on the back of your ID card, or call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227) or 1-877-486-2048, 7 days a week, 24 hours a day.

If you’re moving or getting a new phone number, contact the State of Illinois MyBenefits Service Center at 1-844-251-1777 or 1-844-251-1778 (TTY: 711), Monday to Friday, 8 AM to 6 PM CT.

We help you get medically necessary health care services in the most cost-effective way under your health plan. And we work with you and doctors to evaluate services for medical appropriateness, timeliness and cost. 

Specifically, we: 

  • Base our decisions on appropriateness of care, service and plan coverage 

  • Use nationally recognized guidelines and resources to make changes 

  • Don’t pay or reward providers, employees or others for denying coverage or care 

  • Focus on reviewing the risks of members who aren’t fully using certain services

Doctors and health care companies continuously develop new technologies. This can include anything from a new procedure to a new way to use a device.

When we learn about a new technology, we:

  • Carefully review the latest information and ask experts for their opinions

  • Compare the information with well-known standards

  • Base all of our decisions on making sure you have the right care and services

2023 plan year

You have an Aetna MedicareSM PPO plan that gives you the flexibility to see any provider, in or out of network, at the same cost, according to the costs listed on your plan benefits summary. They just have to be licensed, eligible to receive Medicare payments and willing to accept your plan. 

With a PPO plan, you have the option to choose a primary care physician. But when we know who your doctor is, we can better support your care. 
 

2022 plan year

You’re enrolled in an Aetna Medicare ℠ HMO plan

Your Aetna Medicare ℠ plan is an HMO plan. This requires you to stay within your network of providers to receive coverage except in urgent or emergency situations. View our network of doctors, hospitals or other providers.

Please call us or see your Evidence of Coverage for more information. 

The Centers for Medicare and Medicaid Services periodically issues National Coverage Determinations. They issue these when a service’s or drug’s coverage rules change. 

View a list of coverage determinations