2025 Documents and Forms Library
Member forms, reimbursement forms, request forms
2025 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 a pharmacy or vaccine administered in a provider’s office
2025 Dental Claims Reimbursement
To request repayment for a dental service
2024 Dental Claims Reimbursement
To request repayment for a dental service
2025 Vision Claims Reimbursement
To request repayment for a vision service
2024 Vision Claims Reimbursement
To request repayment for a vision service
Designating Individuals Access to your Personal Health Information
Forms like the Authorization for Release of Protected Health Information (PHI) and the Appointment of Representative (AOR) exist to serve distinct purposes in ensuring that your health information is shared securely and in compliance with privacy regulations. Use these forms to give someone permission to speak with us or act on your behalf, including helping with questions about your coverage or filing a grievance.
Benefit Documents
HMO Basic
Mass Advantage Basic (HMO) Summary of Benefits
Mass Advantage Basic (HMO) Annual Notice of Changes
Mass Advantage Basic (HMO) Evidence of Coverage
HMO Plus
Mass Advantage Plus (HMO) Summary of Benefits
Mass Advantage Plus (HMO) Annual Notice of Changes
Mass Advantage Plus (HMO) Evidence of Coverage
PPO Premiere
Mass Advantage Premiere (PPO) Summary of Benefits
Mass Advantage Premiere (PPO) Annual Notice of Changes
Mass Advantage Premiere (PPO) Evidence of Coverage
PPO Extra
Mass Advantage Extra (PPO) Summary of Benefits
Mass Advantage Extra (PPO) Evidence of Coverage
Enrollment Forms
Complete Enrollment Kit (Ekit)
Star Ratings
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)
Multi-language Interpreter Services
Medicare Prescription Payment Plan Participation Request Form
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