Documents and forms

Summary of Benefits

A Summary of Benefits is a document that lists plan benefits and cost-sharing.

For Worcester County:

For Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, and Suffolk counties:

For all counties in our service area:

Plan comparisons

These brochures outline our benefits and cost information in an easy-to-read chart so that you can compare your options.

  • For Worcester County  (pdf - coming soon)
  • For Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, and Suffolk Counties (pdf - coming soon)

Evidence of Coverage

An Evidence of Coverage is a booklet that is part of your contract with us. It describes your complete benefits as well as how to use the plan.

You can find information about our grievance, coverage determination and appeal (and exceptions for Part D if the plan includes Part D) processes in your Evidence of Coverage. Please refer to the chapter called "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)."

You can also find information about your rights and responsibilities as a member of our plan in your Evidence of Coverage. Please refer to the chapter called "Your rights and responsibilities."

Provider directories

These directories provide lists of network providers, including physicians, specialists, hospitals and other providers.

Or:

Annual Notice of Changes (ANOC)

An ANOC is a document which explains any changes in your coverage, costs, or service area that will be effective on January 1.

Pharmacy

You can also request a printed formulary or directory.

Other benefit documents and forms

Benefit Bank forms

Medicare plan ratings

Enrollment and member change forms

MEDICARE ADVANTAGE

  • 2023 Fallon Medicare Plus enrollment form and instructions (Worcester County - not including FMP Super Saver HMO or FMP Saver No Rx HMO) (pdf)
  • 2023 Fallon Medicare Plus enrollment form and instructions (All other counties - not including FMP Super Saver HMO or FMP Saver No Rx HMO) (pdf)
  • 2023 Fallon Medicare Plus Super Saver HMO and Fallon Medicare Plus Saver No Rx HMO enrollment form and instructions (pdf - coming soon)
  • 2023 Fallon Medicare Plus member change form (Worcester County) (pdf - coming soon)
  • 2023 Fallon Medicare Plus member change form (All other counties) (pdf - coming soon)

Or:

Privacy forms

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., seven days a week.
(Apr.–Sept., we are available 8 a.m.–8 p.m., Mon.–Fri.)

H9001_230122_C | The information on this page was last updated on 10/1/2022.

Every year, Medicare evaluates plans based on a 5-star rating system.