Health Care Publications & Forms
Brochures
Forms
Other
2024 Plan Coverage Documents
Medical Coverage
Aetna Medicare Plan
PPO Enrollees
- 2024 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Part B-Only)
- 2024 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Part B-Only)
- 2024 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Part B-Only)
ESA PPO Enrollees
- 2024 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Parts A & B)
- 2024 Aetna Medicare Plan PPO Annual Notice of Changes (Medicare Part B-Only)
- 2024 Aetna Medicare Plan PPO Evidence of Coverage (Medicare Part B-Only)
- 2024 Aetna Medicare Plan PPO Schedule of Cost Sharing (Medicare Part B-Only)
All Enrollees
Aetna Basic Plan
- 2024 Aetna Basic Plan Medical Plan Description
- 2024 Aetna Basic Plan PPO Schedule of Benefits
- 2024 Aetna Basic Plan Indemnity Schedule of Benefits
- 2024 Aetna Basic Plan PPO Summary of Benefits and Coverage
- 2024 Aetna Basic Plan Indemnity Summary of Benefits and Coverage
- Aetna Member Notice
- Aetna Basic Plan Transform Oncology Program
- Required Notice for the Women’s Health and Cancer Rights Act of 1998
Aetna Basic Health Care Assistance Plan (HCAP)
Prescription Coverage
SilverScript (Medicare Enrollees)
- 2024 SilverScript Evidence of Coverage
- 2024 SilverScript Formulary (List of Covered Drugs)
- 2024 SilverScript Summary of Benefits
- 2024 Low-Cost Generic Drug List
- Notice of Medicare Part D Creditable Coverage
- Mail Service Order Form
CVS Caremark (Non-Medicare Enrollees)
- 2024 CVS Caremark Prescription Medication Plan Description
- 2024 CVS Caremark Performance Drug List — Standard Control Choice (List of Covered Non-Specialty Drugs)
- 2024 CVS Caremark Advanced Control Specialty Formulary (List of Covered Specialty Drugs)
- 2024 Low-Cost Generic Drug List
- Mail Service Order Form
Dental & Vision Coverage
Delta Dental
- 2023–2024 Delta Dental Summary of Dental Plan Benefits
- 2023–2024 Delta Dental Certificate of Coverage
- Delta Dental Special Health Care Needs Benefit