Documents and forms
Summary of Benefits
A Summary of Benefits is a document that lists plan benefits and cost-sharing.
Plan comparisons
This brochure outlines our benefits and cost information in an easy-to-read chart so that you can compare your options.
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. Some 2024 plans are being combined for 2025. To find your correct ANOC, click on the link showing the name of your 2024 plan.
- Fallon Medicare Plus Super Saver HMO - Worcester County (pdf)
- Fallon Medicare Plus Super Saver HMO - Franklin, Hampden and Hampshire Counties (pdf)
- Fallon Medicare Plus Super Saver HMO - Barnstable, Berkshire, Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties (pdf)
- Fallon Medicare Plus Saver No Rx HMO (pdf)
- Fallon Medicare Plus Green HMO - Worcester County (pdf)
- Fallon Medicare Plus Green HMO - Franklin, Hampden and Hampshire Counties (pdf)
- Fallon Medicare Plus Green HMO - Barnstable, Berkshire, Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties (pdf)
- Fallon Medicare Plus Blue HMO - Worcester County (pdf)
- Fallon Medicare Plus Blue HMO - Franklin, Hampden and Hampshire Counties (pdf)
- Fallon Medicare Plus Blue HMO - Barnstable, Berkshire, Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties (pdf)
- Fallon Medicare Plus Orange HMO (pdf)
- Fallon Medicare Plus Central Blue HMO (pdf)
- Fallon Medicare Plus Central Green HMO (pdf)
Pharmacy
You can also request a printed formulary or directory.
Other benefit documents and forms
Benefit Bank forms
Medicare Star Ratings
Enrollment and member change forms
MEDICARE ADVANTAGE
Or:
Privacy forms
- Amendment Request for Personal Information form
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
- Appointment of Representative form
Identify a personal representative—someone Fallon can release your personal information to for purposes of handling a grievance, claim, or coverage determination, or to deal with any level of the appeal process on your behalf. Mail the completed form to Privacy Coordinator, Fallon Health, 1 Mercantile St., Ste. 400, Worcester, MA 01608.
- Authorization for Release of Premium Billing
Information to Veterans Administration (VA)
Use this form to request and authorize Fallon Health to release your monthly premium bill to a VA office for payment.
- Request for an Accounting of Disclosures of Personal Information form
Request a listing of who Fallon has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
- Restriction form
Request a limit on how we use or share your personal information.
- Notice of Privacy Practices
Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., 7 days a week.
(April–September, Monday–Friday)
H9001_250108_C | The information on this page was last updated on 10/1/2024.
Every year, Medicare evaluates plans based on a 5-star rating system.