Other important information and forms

Request a Provider and Pharmacy Directory or Formulary (List of Covered Drugs) and Over-the-Counter (OTC) Drug List

Complete this form to get a Provider and Pharmacy Directory or Formulary and OTC Drug List mailed to you.

NaviCare brochures

  • NaviCare brochure (H9001_N_2018_9 Accepted 09122017, pdf)
  • Folleto de NaviCare en español (muy pronto)
  • Folheto de NaviCare em Português (em breve)

Member magazine: To Your Health

In To Your Health, you’ll find interesting articles on how to improve your general health and well-being, and information about your health insurance plans and programs. Whenever To Your Health is published, we will link to the latest edition below.
Download "To Your Health" (pdf)

Annual Notice of Changes (ANOC)

An ANOC is a document which explains any changes in your coverage or costs that will be effective on January 1, 2018. 

Rights and responsibilities

Below you can find information that explains your rights and protections as a member of NaviCare HMO SNP or NaviCare SCO and also explains what you can do if you think you are being treated unfairly or your rights are not being respected. You can also find information about ending your membership in the plan.

  • If you are enrolled in NaviCare HMO SNP (have Medicare Parts A and B and MassHealth Standard), you can find information about your rights and responsibilities in your Evidence of Coverage (H9001_N_2018_ 2 Accepted 09012017, pdf) in Chapter 7, Your rights and responsibilities.
  • If you are enrolled in NaviCare SCO (have MassHealth Standard alone or MassHealth Standard with Medicare Part A or Part B), you can find information about your rights and responsibilities in your Evidence of Coverage (SCO_2018_3 Approved 08302017, pdf) in Chapter 7, Your rights and responsibilities.

Getting care during a disaster

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.

Generally during a disaster, you can get care from out-of-network providers at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. If you must use an out-of-network pharmacy, you will generally have to pay the full cost at the time you fill your prescription. You can ask us to reimburse you for the cost.

Other important information and forms

Wellness benefit reimbursement form (H9001_N_2018_17 Accepted 09192017, pdf)

Medicare Plan ratings
The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detection and prevention of illness, ratings from patients, patient safety, drug pricing and customer service). The information in this document is an overall plan rating of our plan's performance. 

Fallon Health - CY 2018 Medicare Plan Ratings (H9001_N_2018_46 Accepted 10212017, pdf)

Fallon Health - CY 2017 Medicare Plan Ratings (H9001_N_2017_74 Accepted 10182016, pdf)

Request for Medicare prescription drug coverage determination form (SCO_2017_52 Approved 09222016, pdf)
You or your provider can use this form to request an exception or coverage determination for drugs covered by Medicare Part D. You can also access our online version of this form. Or, you may download the form directly from Medicare. (This link will take you away from NaviCare's website.)

Request for prescription coverage decision SCO-only (SCO_2015_171 Approved 04222015, pdf)
The provider who prescribes your drugs may use this form to request a coverage decision for drugs not covered by Medicare Part D.

Request for redetermination of Medicare prescription drug denial  (SCO_2017_50 Approved 09222016, pdf)
Use this form to request a redetermination of a decision if coverage for a prescription was denied.

Prior authorization form (pdf, 70 KB)
This form may be filled out by the provider who prescribes your drugs that require prior authorization.

CMS' Appointment of Representative form (pdf, 68 KB)
This form may be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process. Return the completed form to Member Appeals and Grievances, Fallon Health, 10 Chestnut St., Worcester, MA 01608.

Amendment Request for Personal Information form (pdf, 36 KB)
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.

Authorization for Release of Personal Information form (pdf, 36 KB)
Allow another individual/entity to receive your personal information from Fallon (such as an employer who is working on your behalf to resolve a claim issue).

Veteran’s Office Authorization for Release of Personal Information form (pdf, 47 KB)
Allow a veteran’s office to receive your personal information from Fallon.

Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Health's notice of privacy practices. This notice of privacy practices was updated on September 23, 2013.

Personal Representative Authorization Form–Accessing Personal Information (SCO_2010_130 Approved 08202010, pdf)
Identify a personal representative—someone Fallon can release your personal information to. Complete a form for each person you want to have as a representative. Return the completed form to Privacy Coordinator, Fallon Health, 10 Chestnut St., Worcester, MA 01608.

Personal Representative Authorization Form–Filing an Appeal or Grievance (SCO_2015_158 Approved 04282015, pdf)
As a NaviCare member, you can use this form to authorize someone to file an appeal on your behalf. Note: This form automatically expires after a year.

Request for an Accounting of Disclosures of Personal Information form (pdf, 36 KB)
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 (pdf, 36 KB)
Request a limit on how we use or share your personal information.

Potential for contract termination

All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, plans decide whether to continue for another year. If NaviCare HMO SNP leaves the program, you will not lose your Medicare or MassHealth Standard coverage (provided that you continue to meet the eligibility requirements for MassHealth). If NaviCare HMO SNP decided not to continue, you would be notified by letter at least 90 days before your coverage ended. The letter would explain your options.

Fallon Health is an HMO plan with a Medicare contract and a contract with the Massachusetts Medicaid program. Enrollment in Fallon Health depends on contract renewal. NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS. NaviCare SCO is available to anyone age 65 and older who has MassHealth Standard and lives in the service area. Individuals who also have Medicare Parts A and B may enroll in NaviCare HMO SNP. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year. You must continue to pay your Medicare Part B premium unless the Commonwealth of Massachusetts pays this premium for you. The Formulary and/or provider network may change at any time. You will receive notice when necessary. To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the NaviCare website.)  Adobe® is a registered trademark of Adobe Systems Incorporated.

H9001_N_2018_10 Approved 10192017
The information on this page was last updated on 10/1/2017.

Medicare Part D online forms