Documents and Forms
Below is a list of WellSense Senior Care Options program materials for 2022
- 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
- Drug List
- Provider and Pharmacy Directory (SCO)
- Provider and Pharmacy Directory (SNP)
- Part D Star Rating
- Multi-Language Insert
2022 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)
- Calificaciones por estrellas Medicare
- Folleto Multi-Idioma
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.
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Welcome to the new wellsense.org! BMC HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire are now one, unified plan under the name WellSense Health Plan. We’re the same dedicated plan you know—offering the same benefits, provider networks, and prescription drug coverage—with a brand new look and feel. To get started, select your plan from the menu and see information just for you.