Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.

Member Forms & Documents

Title Download
2024 – Summary of Benefits PDF
2024 – Official Plan Brochure PDF
2024 – Aetna Medicare Advantage Plan Brochure PDF
2024 Aetna Medicare Advantage Plan for RCBP Summary of Benefits PDF
2024 Annual Notice of Change PDF
2024 Evidence of Coverage PDF
2024 Plan Document Notice PDF
2024 Schedule of Cost Sharing PDF
2024 5 Tier Comprehensive Plus Formulary PDF
2024 Prior Authorization Details PDF
2024 Prescription Drug Guide/Formulary PDF
2024 Step Therapy Detail PDF
2024 Formulary Changes PDF
2024 Non-Part D Rider PDF
2024 Essential Health Supplemental Benefit PDF
PDP Disenrollment Form PDF
2024 Prescription Drug Guide/Formulary PDF
2024 Prescription Drug Guide – Specialty Drugs PDF
2023 – Summary of Benefits PDF
2023 – Official Plan Brochure PDF
2023 – Medicare Plan Brochure PDF
2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage PDF
2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage PDF
2023 Medicare Summary of Benefits Guide PDF
2023 New Member Guide PDF
2023 Making the Most Out of Your Plan PDF
Medicare Rewards Program – Medicare Advantage PDF
Know Where to Go Guide PDF
Contraceptive Management Exception Form PDF
Claim Form – Medical PDF
Claim Form – Mail Order Prescription PDF
Claim Form – Prescription, Retail Pharmacy PDF
Authorization for Release of Protected Health Information (PHI) PDF

Aetna Clinical Policy Bulletins (CPBs)

These documents explain how we make coverage decisions for services covered under our official Plan brochure. The medical, pharmacy and behavioral health CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions.

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