Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.
Member Forms & Documents
| Title | Download |
|---|---|
| 2023 – Summary of Benefits | |
| 2023 – Official Plan Brochure | |
| 2023 – Medicare Plan Brochure | |
| 2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage | |
| 2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage | |
| 2023 Medicare Summary of Benefits Guide | |
| 2023 New Member Guide | |
| 2023 Making the Most Out of Your Plan | |
| 2022 – Official Plan Brochure | |
| Medicare Rewards Program – Medicare Advantage | |
| Know Where to Go Guide | |
| Contraceptive Management Exception Form | |
| 2023 Prescription Drug Guide/Formulary | |
| 2023 Prescription Drug Guide – Specialty Drugs | |
| 2023 Prescription Drug Guide – All Other Drugs | |
| Specialty Quantity Limit Program – Drug List | |
| Performance Drug List | |
| Performance Drug List Change Summary | |
| Claim Form – Medical | |
| Claim Form – Mail Order Prescription | |
| Claim Form – Prescription, Retail Pharmacy | |
| Authorization for Release of Protected Health Information (PHI) | |
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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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