Documents and Forms

Below is a list of WellSense Senior Care Options program forms

• 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.
• 2021 Prescription Reimbursement Form
  Request reimbursement for a prescription that you paid for out-of-pocket.
• 2022 Prescription Reimbursement Form
  Request reimbursement for a prescription that you paid for out-of-pocket.
• Reimbursement Request Form
  Request reimbursement for any medical expenses you may have paid for out-of-pocket.
• Formulario de Solicitud de Reembolso
• 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). Or complete this Appointing a Representative form (Nombramiento de un Representante prepared by the Center for Medicare & Medicaid Services (CMS).
• Revocation of Personal Representative Form
  Remove a personal representative from your healthcare decisions.
• 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.
• 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
  Get reimbursed for your fitness class or club (up to $225 per year).
• Health Rewards Over-the-Counter Reimbursement Form
  Get up to $600 yearly for non-prescription drug store purchases.