• Fallon Medicare Plus - Plan Year 2021
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  • Documents and forms
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• Medicare Supplement
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Documents and forms

Summary of Benefits

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

For Worcester County:

• Fallon Medicare Plus Central Orange HMO
  Fallon Medicare Plus Orange HMO 
  Fallon Medicare Plus Central Green HMO
  Fallon Medicare Plus Green HMO 
  Fallon Medicare Plus Central Blue HMO 
  Fallon Medicare Plus Blue HMO (pdf)

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

• Fallon Medicare Plus Orange HMO 
  Fallon Medicare Plus Green HMO 
  Fallon Medicare Plus Blue HMO (pdf)

For all counties in our service area:

• Fallon Medicare Plus Super Saver HMO and Fallon Medicare Plus Saver No Rx HMO (pdf)

Plan comparisons

These documents show benefit and cost information in a chart format so that you can compare your plan options.

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

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 section 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 section called "Your rights and responsibilities."

• Fallon Medicare Plus Blue HMO (pdf)
• Fallon Medicare Plus Green HMO (pdf)
• Fallon Medicare Plus Orange HMO  (pdf)
• Fallon Medicare Plus Central Blue HMO (pdf)
• Fallon Medicare Plus Central Green HMO (pdf)
• Fallon Medicare Plus Central Orange HMO (pdf)
• Fallon Medicare Plus Super Saver HMO (pdf)
• Fallon Medicare Plus Saver No Rx HMO (pdf)

Provider directories

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

• Fallon Medicare Plus Provider Directory (pdf, last updated 12/31/2020)
• Fallon Medicare Plus Central Provider Directory (pdf, last updated 12/31/2020)

Or:

• Request a printed directory

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.

• Fallon Medicare Plus Saver No Rx HMO - Barnstable County (pdf)
• Fallon Medicare Plus Saver No Rx HMO - Berkshire County (pdf)
• Fallon Medicare Plus Saver No Rx HMO - Worcester County (pdf)
• Fallon Medicare Plus Saver No Rx HMO - Hampden and Hampshire Counties (pdf)
• Fallon Medicare Plus Saver No Rx HMO - Franklin County (pdf)
• Fallon Medicare Plus Saver No Rx HMO - Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties (pdf)
• Fallon Medicare Plus Super Saver HMO - Barnstable County (pdf)
• Fallon Medicare Plus Super Saver HMO - Berkshire County (pdf)
• Fallon Medicare Plus Super Saver HMO - Hampden and Hampshire Counties (pdf)
• Fallon Medicare Plus Super Saver HMO - Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk and Worcester Counties (pdf)
• Fallon Medicare Plus Super Saver HMO - Franklin County (pdf)
• Fallon Medicare Plus Green HMO - Barnstable County (pdf)
• Fallon Medicare Plus Green HMO - Berkshire County (pdf)
• Fallon Medicare Plus Green HMO - Worcester County (pdf)
• Fallon Medicare Plus Green HMO - Hampden and Hampshire Counties (pdf)
• Fallon Medicare Plus Green HMO-  Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties (pdf)
• Fallon Medicare Plus Green HMO - Franklin County (pdf)
• Fallon Medicare Plus Blue HMO - Barnstable County (pdf)
• Fallon Medicare Plus Blue HMO - Berkshire County (pdf)
• Fallon Medicare Plus Blue HMO - Worcester County (pdf)
• Fallon Medicare Plus Blue HMO - Franklin County (pdf)
• Fallon Medicare Plus Blue HMO - Hampden and Hampshire Counties
• Fallon Medicare Plus Blue HMO - Essex, Plymouth and Suffolk Counties (pdf)
• Fallon Medicare Plus Blue HMO - Bristol, Middlesex and Norfolk Counties (pdf)
• Fallon Medicare Plus Orange HMO - Barnstable and Berkshire Counties (pdf)
• Fallon Medicare Plus Orange HMO - Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk and Worcester Counties (pdf)
• Fallon Medicare Plus Central Blue HMO (pdf)
• Fallon Medicare Plus Central Green HMO (pdf)
• Fallon Medicare Plus Central Orange HMO (pdf)

Pharmacy

• Fallon Health 2021 Pharmacy Directory (pdf, last updated 12/31/2020)
• Fallon Medicare Plus 2021 Formulary (pdf, last updated 10/1/2020)
• Prior authorization form  (pdf) 
  This form may be filled out by the provider who prescribes your drugs that require prior authorization (approval in advance)
• Request for Medicare prescription drug coverage determination form  (pdf)
  You or your provider can use this form to request an exception or coverage determination. You can also access an online version of this form. Or, download the form from Medicare's website. (This link takes you away from the Fallon Medicare Plus website.)
• Part D appeal form
  Use this online form to start a Medicare Part D appeal.
• Request for redetermination of Medicare prescription drug denial  (pdf)
  Use this form to request a redetermination of a decision if coverage for a prescription was denied.

You can also request a printed formulary or directory.

Other benefit documents

• Dental Addendum (pdf)
• List of Covered Hearing Aids (pdf)

Benefit Bank forms

• Benefit Bank reimbursement form (pdf)
• Tips for using your Benefit Bank card (pdf)

Medicare plan ratings

• Fallon Health - CY 2020 Medicare Plan Ratings 
  Fallon Health - CY 2021 Medicare Plan Ratings

Enrollment and member change forms

MEDICARE ADVANTAGE

• 2021 Fallon Medicare Plus enrollment form and instructions (Worcester County) (pdf)
• 2021 Fallon Medicare Plus enrollment form and instructions (All other counties) (pdf)
• 2021 Fallon Medicare Plus member change form (Worcester County) (pdf)
• 2021 Fallon Medicare Plus member change form (All other counties) (pdf) 

Or:

• Request to have an information kit and enrollment form mailed to you

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. This form may also be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process. Mail the completed form to Privacy Coordinator, Fallon Health, 10 Chestnut St., 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