2023 Plan Documents
2023
Documents and Forms Library
Benefits Documents
HMO Basic
Mass Advantage Basic (HMO) Summary of Benefits
Mass Advantage Basic (HMO) Evidence of Coverage
Mass Advantage Basic (HMO) Part B Prescription Drugs Addendum (effective 4/1/2023)
HMO Plus
Mass Advantage Plus (HMO) Summary of Benefits
Mass Advantage Plus (HMO) Evidence of Coverage
Mass Advantage Plus (HMO) Part B Prescription Drugs Addendum (effective 4/1/2023)
PPO
Mass Advantage Premiere (PPO) Summary of Benefits
Mass Advantage Premiere (PPO) Evidence of Coverage
Mass Advantage Premiere (PPO) Part B Prescription Drugs Addendum (effective 4/1/2023)
Additional Benefits
Over the Counter Savings Catalog
Personal Medical Alert System Benefit
Medication Therapy Management (MTM)
Enrollment Forms
Complete Enrollment Kit (Ekit)
Enrollment Request Form with Instructions
Other
Low Income Subsidy (LIS) Rider
2023 Prior Authorization Policy