Documents and forms

Summary of Benefits

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


For Worcester and Franklin Counties:

For Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties:

For Hampden and Hampshire Counties:

For Barnstable and Berkshire Counties:

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, compliants)."

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.


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.


You can also request a printed formulary or directory.

Other benefit documents

Medicare plan ratings

Enrollment and member change forms



Reimbursement forms

Privacy forms

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday.
(Oct. 1–March 31, seven days a week.)

H9001_190086_C | The information on this page was last updated on 10/1/2018.

Fallon Health is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Fallon Health depends on contract renewal.

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