Other important information and forms
Request a Provider and Pharmacy Directory, Member Handbook, or Formulary (List of Covered Drugs) and Over-the-counter and Additional MassHealth Covered Drugs list
Complete this form to get a Provider and Pharmacy Directory, Member Handbook (otherwise known as the Evidence of Coverage), or Formulary and Over-the-counter and Additional MassHealth Covered Drugs list mailed to you.
NaviCare brochures
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 plan and programs. Whenever To Your Health is published, we'll link to the latest edition below.
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.
2027
2026
Rights and responsibilities
You can find information about your rights and responsibilities in your NaviCare HMO SNP and NaviCare NHC HMO SNP Member Handbook in the chapter called “Your rights and responsibilities.”
Getting care during a disaster
During an emergency or disaster, Fallon Health will make sure you have access to your health plan benefits. The rules for getting care may change for a short time in areas where one of these has happened:
- The President has declared an emergency or disaster.
- The governor has declared an emergency or disaster.
- The Secretary of the Department of Health and Human Services has declared a public health emergency.
Seeing your doctors or other providers in a disaster or emergency
During a qualified disaster or emergency, if you can’t use a network provider:
- You can see certain doctors or go to certain hospitals that accept Medicare patients, even if the doctor or hospital isn't in your plan's network and your health care need isn't an emergency.
- You can get care from out-of-network providers at the in-network cost-sharing amounts.
- You may not need a referral or prior authorization for out-of-network services.
Filling your prescriptions in a disaster or emergency
If you can't reasonably get to a network pharmacy, you can use an out-of-network pharmacy to fill your prescriptions. For refills, we'll remove restrictions that stop you from getting refills too soon and also cover the maximum supply of your refill if you ask for it.
When you buy your drugs at an out-of-network pharmacy, you may have to pay full cost for the drugs at the time you fill your prescriptions. If you pay full cost for the drugs, save your receipts so you can ask your plan if it'll refund you for your costs. Ask your plan how to submit your claim.
For more information
In the case of a disaster or emergency, we’ll keep you informed about how to receive covered care and prescription drugs. For more information,1-877-790-4971 (TTY 711), 8 a.m. to 8 p.m., Monday through Friday (7 days a week, Oct. 1 through March 31).
Other important information and forms
Wellness benefit reimbursement form (H8928_260132_C, pdf)
Request for Payment of Medical Services form (H9001_260281_C, H8928_260282_C, pdf)
Medicare Part D claim form (pdf)
2026 Save Now reimbursement form (H8928_260104_C, pdf)
2026 Save Now card eligible items (H8928_260055_C, pdf)
2027 Save Now reimbursement form (coming soon, pdf)
2027 Save Now card eligible items (coming soon, pdf)
Friends and family benefit reimbursement form (H8928_260153_C, 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 2027 Medicare Star Ratings (coming soon)
Fallon Health - CY 2026 Medicare Star Ratings
Request for Medicare prescription drug coverage determination form (H8928_220030_C Approved 11022021, 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 redetermination of Medicare prescription drug denial (H8928_260228_C, pdf)
Use this form to request a redetermination of a decision if coverage for a prescription was denied.
Part D appeal form
Use this online form to start a Medicare Part D appeal.
Part D prior authorization form (pdf)
This form may be filled out by the provider who prescribes your drugs that require prior authorization.
Appointment of Representative form (pdf)
Identify a personal representative—someone Fallon Health can release your personal information to for purposes of handling a grievance, claim, or coverage determination, or to deal with any level of the appeal process on your behalf. Return the completed form to Privacy Coordinator, Fallon Health, 1 Mercantile St., Ste. 400, Worcester, MA 01608.
Amendment Request for Personal Information form (pdf)
Request changes to your record if you think it's inaccurate or incomplete. This form isn't required for corrections to your address, date of birth, or name.
Authorization for Release of Personal Information form (pdf)
Allow another individual/entity to receive your personal information from Fallon Health (such as family members, friends, landlords, etc.).
Notice of Privacy Practices (pdf)
This document is Fallon Health's notice of privacy practices.
Request for an Accounting of Disclosures of Personal Information form (pdf)
Request a listing of who Fallon Health has shared your information with for reasons other than treatment, payment, or health care operations.
Restriction form (pdf)
Request a limit on how we use or share your personal information.
Online resources
Fallon Health's other options for older adults - decision guide (This link takes you away from the NaviCare website.)
Our spectrum of health insurance plans for older adults that fit your lifestyle and level of care
Quality at Fallon Health (This link takes you away from the NaviCare website.)
Fallon Health aims to assure that safe, effective, patient-centered, timely, efficient, and equitable clinical care and services are provided to members.
Preventive care guidelines (This link takes you away from the NaviCare website.)
Guidelines for clinical practice and preventive care
Advance care directives (This link takes you away from the NaviCare website.)
Information about advance care planning, health care proxies, and living wills
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 leaves the program, you won't lose your Medicare or MassHealth Standard coverage (provided that you continue to meet the eligibility requirements for MassHealth Standard). If NaviCare HMO SNP and/or NaviCare NHC HMO SNP decided not to continue, you'd be notified by letter at least 90 days before your coverage ended. The letter would explain your options.
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H8928_270025_M Accepted 09302026
The information on this page was last updated on 10/1/2026.