Documents and forms

Below is a list of WellSense Senior Care Options program materials for 2025

• Annual Notice of Change (for Medicaid and Medicare) (updated 10/1/24)
• Annual Notice of Change (for Medicaid only) (updated 10/1/24)
• Summary of Benefits (for Medicaid and Medicare) (updated 10/1/24)
• Summary of Benefits (for Medicaid only) (updated 10/1/24)
• Evidence of Coverage (for Medicaid and Medicare) (updated 10/1/24)
• Evidence of Coverage (for Medicaid only) (updated 10/1/24)
• LIS Premium Summary Chart (updated 10/1/24)
• List of Covered Drugs (updated 10/30/24)
• Provider and Pharmacy Directory (SNP) (updated 11/27/24)
• Provider and Pharmacy Directory (SCO) (updated 11/27/24)
• Part D Star Rating (updated 10/30/24)

• Aviso Anual de Cambios (para Medicaid y Medicare) (updated 10/1/24)
• Aviso Anual de Cambios (solo para Medicaid) (updated 10/1/24)
• Resumen de Beneficios (para Medicaid y Medicare) (updated 10/1/24)
• Resumen de Beneficios (solo para Medicaid) (updated 10/1/24)
• Evidencia de Cobertura (para Medicaid y Medicare) (updated 10/7/24)
• Evidencia de Cobertura (solo para Medicaid) (updated 10/23/24)
• Gráfico de Resumen para LIS Premium (updated 10/1/24)
• Lista de Medicamentos (updated 10/30/24)
• Directorio de Proveedores y Farmacias (SNP) (updated 11/27/24)
• Directorio de Proveedores y Farmacias (SCO) (updated 11/27/24)
• Calificación 2024 de Medicare con Estrellas (updated 10/30/24)

Below is a list of WellSense Senior Care Options program forms

• Appointment of Representative Form
  • Appointment of Representative Form (large print) (updated 7/14/23)
  • Appointment of Representative Form (Spanish) (updated 8/3/23)

• Assign a Healthcare Proxy Form (updated 6/26/23)
  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.
• Assign or Revoke a Personal Representative form (updated 7/15/24)
  Name someone you know and trust to communicate with our plan on your behalf.
  • Formulario para designar un representante personal (updated 7/15/24)
  • Formulário de Indicação de Representante Pessoal (updated 7/15/24)
  • Fòm pou Deziyen yon Reprezantan Pèsonèl (updated 7/15/24)
• Disenrollment form (updated 2/28/24)
  • Solicita la desafiliación formulario (updated 2/29/24)
• Model Drug Coverage Determination Form (Medicaid Only) (updated 12/11/23)
  Request approval of a prescription drug that is not covered or has restrictions.
• Model Drug Coverage Determination Form (Medicaid + Medicare) (updated 12/11/23)
  Request approval of a prescription drug that is not covered or has restrictions.
• Request for Redetermination of Medicare Prescription Drug Denial Form (updated 3/16/23)
  Appeal a decision about drug coverage that you do not agree with.
• Prescription Reimbursement Form (updated 7/26/23)
  Request reimbursement for a prescription that you paid for out-of-pocket.
  • Formulario de reembolso de recetas (updated 5/13/24)
• Over-the-Counter Reimbursement Form (updated 3/16/23)
  Request reimbursement for the monthly $75 over-the-counter (OTC) card allowance. 
• Reimbursement Request Form (updated 3/16/23)
  Request reimbursement for any medical expenses you may have paid for out-of-pocket.
  • Formulario de Solicitud de Reembolso (updated 3/16/23)
• Personal Care Attendant (PCA) UM Notification Form (updated 3/16/23)
• PCP Selection Form (updated 6/5/23)
  Select or change your Primary Care Provider (PCP)
• PHI Permissions for Use Form (updated 7/27/23)
  Let us share your Protected Health Information (PHI) with those who need it to provide healthcare services to you.
  • Permisos para el uso de información protegida de salud (updated 7/27/23)
• Release of Information Form (updated 7/15/24)
  Request that we share your information with a third party
  • Formulario de divulgación de información (updated 7/15/24)
  • Formulário de Divulgação de Informações (updated 7/15/24)
  • Fòm pou Pibliye Enfòmasyon (updated 7/15/24)
• Release of Reproductive Healthcare Attestation (updated 10/21/24)
• Request for Access to Information Form (updated 2/14/24) 
  • Formulario de solicitud de acceso a la información