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1. Applicant Info

2. Eligibility

3. Review & Submit

Your current selection:

Aetna Medicare Dual Choice (PPO D-SNP)

Contract ID: H5521-539-000

N/A

Application Information

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Enrollment Form

Who is completing this application?

Applicant (Yourself)

Power of Attorney

First Name

Middle Name (Optional)

Last Name

Gender

Male

Female

Contact Information

Permanent Address Line 1 (Do not enter a PO Box)

Permanent Address Line 2

City

State

Zip Code

Mailing Address, if different from your permanent address (PO Box allowed)

Mailing Address Line 1 (Do not enter a PO Box)

Mailing Address Line 2

City

State

Zip Code

I do not have a permanent address

Date of Birth

Phone

Is this a mobile phone number? (Optional)

Yes

No

Email (Optional)

Preferred spoken language (Optional)

Preferred written language (Optional)

Select one if you want us to send you information in an accessible format (optional)

Race and Ethnicity (Optional)

Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Puerto Rican

Yes, another Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Cuban

I prefer not to answer

What's your race? Select all that apply.

American Indian or Alaska Native

Asian Indian

Black or African American

Chinese

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Guamanian or Chamorro

Japanese

Korean

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Other Pacific Islander

Samoan

Vietnamese

White

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If you need help, please call 727-261-2161 Mon – Fri, 9am – 8pm ET for licensed insurance agents who can assist with finding information on available Medicare Advantage, Medicare Supplement Insurance and Prescription Drug Plans.

We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

VBID Plans: Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of approved benefits. Unused amounts will expire at the end of the month or quarter. Transportation services may be issued as one-way trips and are provided on an annual basis.

* Depending on service provided. See Summary of Benefits for more details.

Insurance Ad – No Government Affiliation. This ad is not from the government. It’s from Insurance Benefits Group, LLC (d/b/a InsBenefitsPlaza), an independent Medicare insurance agency that sells plans from several insurance companies. The Medicare plans represented are PDP, HMO, PPO or PFFS plans with a Medicare contract. Enrollment in plans depends on contract renewal. Enrollment in a plan may be limited to certain times of the year. Eligibility may require a Special or Initial Enrollment Period. InsBenefitsPlaza and Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

By initiating a chat or scheduling a call, you are agreeing to be contacted by a licensed sales agent by email, text message or phone call (including by autodialer or prerecorded/artificial voice) to discuss information about Medicare plans. This is a solicitation for insurance. Standard messaging rates apply.

Benefits shown are for the 2025 plan year. Not all plans offer all benefits mentioned. Benefits may vary by carrier and location. Deductibles, copays, and coinsurance may apply. Limitations and exclusions may apply. $0 premium plans are not available in all areas. You must continue to pay your Part B Premium.

InsBenefit’s website is operated by Insurance Benefits Group, LLC, a licensed health insurance agency doing business as InsBenefitsPlaza. The purpose of this site is the solicitation of insurance. Contact may be made by an insurance agent/producer or insurance company.

Your information and use of this site is governed by our most recent Terms of Service and Privacy Policy.

InsBenefitsPlaza is your Independent Medicare Insurance Advisor.

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Your current selection:

Aetna Medicare Dual Choice (PPO D-SNP)

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