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Review your Evidence of Coverage 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 & 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 (PDF) | Español (PDF)
As a member of 1199SEIU you are eligible to receive of $200 every 12 months toward the purchase of any eyewear for the purpose of vision correction. This benefit is limited to lenses, frames, contact lenses. You have two options to submit for reimbursement:
Option 1 (no claim form)
If you were billed directly by a provider, just mail us a copy of the itemized receipt that includes:
- Date of service
- Name of provider
- The Tax ID or NPI number of the provider of service
- Address of provider
- Proof of payment
You can mail us the information to the claim form address on your ID card.
Option 2 (medical claim reimbursement form - included below):
As a member of 1199SEIU you are eligible to receive $500 every 36 months toward the purchase of a hearing aid. You have two options to submit for reimbursement.
Option 1 (no claim form)
If you were billed directly by a provider, just mail us a copy of the itemized receipt that includes:
Date of service
Name of provider
The Tax ID or NPI number of the provider of service
Address of provider
Brief description of services or items for which member is requesting reimbursement (e.g., frames, lenses, etc.) and/or procedure codes
Diagnosis codes
Member's ID, name, DOB, address and phone number
Proof of payment
You can mail us the information to the claim form address on your ID card.
Option 2 (medical claim reimbursement form - included below):
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)
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 & 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)
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)
Exceptions, appeals & 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.
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 ${groupPhoneNumber} ${tty}, ${memberhours}.
Medicare Helpline & 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 TTY: 1-877-486-2048, 7 days a week, 24 hours a day.
If you’re moving or getting a new phone number, let us know right away.
Just call our 1199SEIU Retiree Health Benefits Representatives at 1-646-473-8666 (TTY: 711), Monday to Friday, 8:30 AM to 5 PM ET. If you live outside New York City, call 1-800-892-2557 (TTY: 711), Monday to Friday, 8:30 AM to 6 PM ET.
You can also visit my1199benefits.org to update your information.
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
If you’re enrolled in an Aetna Medicare PPO plan:
PPO plans have a network of doctors and hospitals for you to get care. You can go out of the network for care, but it usually costs you more.
If you’re enrolled in an Aetna Medicare plan (PPO) with Extended Service Area (ESA):
A PPO plan with an extended service area (ESA) 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 with ESA, you have the option to choose a primary care physician. But when we know who your doctor is, we can better support your care.
View our network of doctors and providers
Please call us or see your Evidence of Coverage for more information, including the cost share for out‐of‐network services.
The Centers for Medicare & Medicaid Services periodically issues National Coverage Determinations. They issue these when a service’s or drug’s coverage rules change.