Documents and Forms Library
Member forms, reimbursement forms, request forms

Documents and Forms Library
Claims
Medical Claims Reimbursement
To request repayment for a medical service
Pharmacy Claims Reimbursement
To request repayment for a prescription filled at the pharmacy
Dental Claims Reimbursement
To request repayment for a dental service
Vision Claims Reimbursement
To request repayment for a vision service
HIPAA Request Information*
Appointment of Representative Instructions
How to appoint someone other than yourself--such as a relative, friend, advocate, or attorney--to act on your behalf.
Appointment of Representative
Complete this form to appoint someone as your representative. Both you and your representative need to sign this form.
Protected Health Information (PHI) Release
Complete this form to allow us to share specific health information, otherwise protected, with an individual or entity you clearly authorize.
Substance Use Disorder (PHI) Release
Complete this form to allow us to share your substance use disorder information with an individual or entity.
*Health Insurance Portability and Accountability Act
Benefit Documents
HMO Basic
Mass Advantage Basic (HMO) Summary of Benefits
Mass Advantage Basic (HMO) Evidence of Coverage
Mass Advantage Basic (HMO) Annual Notice of Changes
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) Annual Notice of Changes
Mass Advantage Plus (HMO) Part B Prescription Drugs Addendum (effective 4/1/2023)
PPO Premiere
Mass Advantage Premiere (PPO) Summary of Benefits
Mass Advantage Premiere (PPO) Evidence of Coverage
Mass Advantage Premiere (PPO) Annual Notice of Changes
Mass Advantage Premiere (PPO) Part B Prescription Drugs Addendum (effective 4/1/2023)
Enrollment Forms
Complete Enrollment Kit (Ekit)
Additional Member Information
Getting Care During a Disaster
Learn more about how to get care during a disaster.
Low Income Subsidy (LIS) Rider
This document shows how much lower a member's monthly premium will be if they are getting extra help from Medicare in paying for their Medicare prescription drug plan.
If you are not receiving extra help but think you may qualify, you can research whom to contact to find out more.
Best Available Evidence (BAE)
CMS created the "best available evidence" process requiring plans to establish appropriate cost-sharing for low-income members when presented with evidence that the member's information was not accurate. More information can be found on the Medicare website.
Authorization Agreement for Automatic Withdrawl (ACH)
Interoperability
Interoperability Developer Toolkit
Information for developers on how to connect to the Mass Advantage interoperability code suite.
Questions?
We’re here to help.
From October 1 to March 31, we’re available 7 days a week from 8 am to 8 pm EST. From April 1 to September 30, we’re available Monday through Friday from 8 am to 8 pm EST.
For HMO Members: (844) 918-0114
For PPO Members: (844) 915-0234
TTY: 711