Documents and Forms
Below is a list of WellSense Senior Care Options program materials for 2023
- Annual Notice of Change (for Medicaid and Medicare)
- Annual Notice of Change (for Medicaid only)
- Summary of Benefits (for Medicaid and Medicare)
- Summary of Benefits (for Medicaid only)
- Evidence of Coverage (for Medicaid and Medicare)
- Evidence of Coverage (for Medicaid only)
- LIS Premium Summary Chart
- List of Covered Drugs
- Provider and Pharmacy Directory (SNP)
- Provider and Pharmacy Directory (SCO)
- Part D Star Rating
2023 Materiales en Español para Miembros
- Aviso Anual de Cambios (para Medicaid y Medicare)
- Aviso Anual de Cambios (solo para Medicaid)
- Resumen de Beneficios (para Medicaid y Medicare)
- Resumen de Beneficios (solo para Medicaid)
- Evidencia de Cobertura (para Medicaid y Medicare)
- Evidencia de Cobertura (solo para Medicaid)
- Gráfico de Resumen para LIS Premium
- Lista de Medicamentos
- Directorio de Proveedores y Farmacias (SCO)
- Directorio de Proveedores y Farmacias (SNP)
- Calificación 2023 de Medicare con Estrellas
Below is a list of WellSense Senior Care Options program forms
- Assign a Healthcare Proxy Form
Name someone to make decisions about your medical care if you can no longer speak for yourself. This form is prepared by Massachusetts Health Decisions. - Model Drug Coverage Determination Form (Medicaid Only)
Request approval of a prescription drug that is not covered or has restrictions. - Model Drug Coverage Determination Form (Medicaid + Medicare)
Request approval of a prescription drug that is not covered or has restrictions. - Request for Redetermination of Medicare Prescription Drug Denial Form
Appeal a decision about drug coverage that you do not agree with. - Prescription Reimbursement Form
Request reimbursement for a prescription that you paid for out-of-pocket. - Over-the-Counter Reimbursement Form
Request reimbursement for the monthly $75 over-the-counter (OTC) card allowance. - Reimbursement Request Form
Request reimbursement for any medical expenses you may have paid for out-of-pocket. - Personal Care Attendant (PCA) UM Notification Form
- PCP Selection Form
Select or change your Primary Care Provider (PCP) - Personal Representative Designation Request Form
Name someone you know and trust to communicate with our plan on your behalf (for example, to submit requests or file appeals for you).- Nombramiento de un Representante - prepared by the Center for Medicare & Medicaid Services (CMS)
- Appointment of Representative Form (large print)
- Revocation of Personal Representative Form
Remove a personal representative from your healthcare decisions. - PHI Permissions for Use Form
Let us share your Protected Health Information (PHI) with those who need it to provide healthcare services to you. - Release of Information Form
Request that we share your information with a third party - Fitness Reimbursement Form for 2022
Get reimbursed for your fitness class or club in 2022 (up to $225 per year).
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