Documents and forms
Summary of Benefits
A Summary of Benefits is a document that lists plan benefits and cost-sharing.
For Worcester County:
For Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth and Suffolk Counties:
For all counties in our service area:
Plan comparisons
These documents show benefit and cost information in a chart format so that you can compare your plan 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 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."
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.
- 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
You can also request a printed formulary or directory.
Other benefit documents
Benefit Bank forms
Medicare plan ratings
Enrollment and member change forms
MEDICARE ADVANTAGE
Or:
Privacy forms
Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., seven days a week
(From Jan.–Sept., 8 a.m.–5 p.m., Mon.–Fri.)
H9001_210085_C | The information on this page was last updated on 10/1/2020.
Every year, Medicare evaluates plans based on a 5-star rating system.