Other important information and forms

Request a Provider and Pharmacy Directory, Evidence of Coverage (with Dental Addendum), or Formulary (List of Covered Drugs) and Over-the-Counter (OTC) Drug List

Complete this form to get a Provider and Pharmacy Directoryan Evidence of Coverage (with Dental Addendum), or Formulary and OTC Drug 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 plans and programs. Whenever To Your Health is published, we will 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. 


Rights and responsibilities

You can find information about your rights and responsibilities in your NaviCare SCO Evidence of Coverage  or NaviCare HMO SNP Evidence of Coverage  in Chapter 7, “Your rights and responsibilities.”

Getting care during a disaster

If the Governor of Massachusetts, 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 (H8928_220729_C, pdf)
Request for Payment of Medical Services form (H9001_220621_C, H8928_220545_C, pdf)
Medicare Part D claim form (pdf)
Healthy Food card services received form (H8928_220561_C, pdf)
Save Now reimbursement form (H8928_230118_C, pdf)
Self-Care reimbursement form (H8928_230119_C, pdf)
Self-Care card eligible items (H8928_230495_C , pdf)
CTS Friends and Family reimbursement form (H8928_220282_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 2023 Medicare Plan 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 prescription coverage decision SCO-only (SCO_220031_C Approved 11022021, 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  (H8928_220048_C Approved 11042021, 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.

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

Appointment of Representative form (pdf, 68 KB)
Identify a personal representative—someone Fallon 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, 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).

Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Health's notice of privacy practices.

Personal Representative Authorization Form - For NaviCare SCO members only 
Identify a personal representative—someone Fallon can release your personal information to and/or give permission to someone to handle an appeal or grievance for you. 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. (Not for use by members of NaviCare HMO SNP.)

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.

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 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 Standard). 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. Every year, Medicare evaluates plans based on a 5-star rating system. 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.

The information on this page was last updated on 10/1/2022.

Medicare Part D online forms