Helpful documents

Simply click on the links below to download each document you are interested in.

Summary of Benefits

A summary of benefits is a booklet that compares our benefits with Original Medicare benefits.

Benefits-at-a-glance:

Provider and Pharmacy Directory

This directory provides a list of network providers, including physicians, specialists, hospitals, pharmacies and other providers. This directory is current as of August 2, 2011. Some providers may have been added or removed from this list after the directory was created. Use our "Find a doctor" tool for the most up-to-date information.

Fallon Senior Plan HMO Provider and Pharmacy Directory (H9001_2012_720_188 CMSApproved 07262011, pdf)
Fallon Senior Plan HMO Guía de proveedores y farmacias (H9001_2012_720_188SP CMSApproved 07262011, pdf - 14MB)

Evidence of Coverage

An Evidence of Coverage is a booklet that we provide once you become a member. It’s part of your contract with us and it describes your complete benefits as well as how to use the plan.

You can also find information about our grievance, coverage determination and appeal (and exceptions for 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)."

Other documents and information

2012 Medicare Plan rankings
The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing 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 Community Health Plan - CY 2012 Medicare Plan Ratings (H9001_2012_720_299 File&Use 10182011, pdf)
Fallon Community Health Plan - Evaluaciones de Medicare del Plan para el año actual 2012 (H9001_2012_720_299SP File&Use 10182011, pdf)

Medicare 101 (coming soon, pdf)
Our easy-to-follow "Medicare as easy as 1-2-3" guide gives you a high-level primer on Medicare.

Fallon Senior Plan HMO eyewear benefit certificate (H9001_2012_670_171 CMSApproved 11282011, pdf) 
The certificate entitles the member to a benefit of up to $150 for eyeglasses, contact lenses, lens replacement, fitting, adjustment or repair every year.

Medication Therapy Management Program
A Medication Therapy Management (MTM) Program is a free service that we may offer through our Medicare Advantage Prescription Drug plans. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected.

Appeals, grievances and exceptions for Medicare Part D  (H9001_2011_720_115_r1 CMSApproved 07012011, pdf) 
Apelaciones, quejas y excepciones para Medicare Parte D (H9001_2011_720_115SP_r1 CMSApproved 07012011, pdf)
This document explains the process for filing an appeal or grievance for drugs covered under Medicare Part D, and how to request an exception to the formulary as a Fallon Senior Plan member. You can also initiate a Medicare Part D appeal or grievance using our online form.

You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call Customer Service at 1-800-325-5669 (TTY users, please call TRS Relay 711), 8 a.m. to 8 p.m., Monday through Friday. (From October 15 through February 14, we're available seven days a week.)

You may also use Medicare's complaint form that is available online at Medicare.gov.

Appeals and grievances (non-Part D) (H9001_2012_720_114 CMSApproved 08032011, pdf) 
Apelaciones y quejas (no Parte D) (H9001_2012_720_114SP CMSApproved 08032011, pdf)
This document explains the process for filing an appeal or grievance for all other issues not related to Medicare Part D as a Fallon Senior Plan member.

You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call Customer Service at 1-800-325-5669 (TTY users, please call TRS Relay 711), 8 a.m. to 8 p.m., Monday through Friday. (From October 15 through February 14, we're available seven days a week.)

You may also use Medicare's complaint form that is available online at Medicare.gov.

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

Request for Medicare prescription drug coverage determination form (pdf)
Use this form for you to request an exception or coverage determination. You can also access an online version of this form.

Medicare Part D coverage determination request form (pdf)
The provider who prescribes your drugs may use this form to request an exception or coverage determination. You can also access an online version of this form

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

CMS Appointment of Representative form (pdf)
This form may be used to appoint someone to handle a grievance, coverage determination, or in dealing with any level of the appeal process.

Privacy forms
Because Fallon Community Health Plan is dedicated to protecting your privacy, we are strict about who can see your information. However, there may be times that you want to allow certain other people to see your information or perhaps get a copy for yourself. FCHP makes this easy for you to do by printing off the appropriate form and submitting it according to the directions on the form.

Amendment Request for Personal Information form (pdf)
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.

Personal Representative Authorization Form - Accessing Personal Information (pdf)
Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.

Personal Representative Authorization Form – Filing an Appeal (H9001_2011_735_11 CMSApproved 05022011, pdf)
This form is to be used by Fallon Senior Plan members to authorize someone to file an appeal on the member’s behalf. Note: This form automatically expires after a year.

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

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

Request for an Accounting of Disclosures of Personal Information form (pdf, 36 KB)
Request a listing of who FCHP 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.

Resources

Here is a listing of resources for people with Medicare. Clicking the links below will cause you to leave the Medicare Advantage Fallon Senior Plan-specific Web site pages.

The Centers for Medicare & Medicaid Services - www.cms.hhs.gov
The Centers for Medicare & Medicaid Services (CMS), the federal agency within the U.S. Department of Health and Human Services, administers the Medicare and Medicaid programs. Their site provides answers to common questions and information about important legislation.

Medicare - www.medicare.gov
You can call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

Social Security Administration - www.socialsecurity.gov
You may be eligible for extra help with your Medicare prescription drug coverage. Call Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.

Resources for Massachusetts seniors - www.800ageinfo.com
Massachusetts’ largest online resource of elder services, programs and information, including information about the state’s SHINE program, local Councils on Aging and more.

SilverSneakers® - www.silversneakers.com
Interested in learning more about the SilverSneakers Fitness Program or the SilverSneakers Steps? Find general program information, read what participants think of the program and learn how to get involved at their Web site. SilverSneakers® is a registered trademark of Healthways.

FCHP's other options for older adults
Our spectrum of health insurance plans for older adults that fit your lifestyle and level of care.

  • Fallon Senior PlanTM Medicare Supplement options
    Our Medicare Supplement plans give you the freedom to see any provider that accepts Medicare. There are no network restrictions and little to no out-of-pocket expenses. No primary care provider. No referrals. No copays for most services. No hassles and practically no paperwork!
  • NaviCare® HMO SNP - www.navicare.org
    NaviCare is a program that combines all the benefits that are covered by Medicare and MassHealth Standard into one program. NaviCare helps you get the most out of your Medicare and MassHealth Standard benefits and offers you extra services that can help you stay healthy at no extra cost.
  • Summit ElderCare® - www.summiteldercare.org
    Fallon Community Health Plan has continued our commitment to becoming the premier health care services company in New England by being not only a provider of health insurance, but also the only health plan in Massachusetts to be a provider of health care—through Summit ElderCare, our Program of All-Inclusive Care for the Elderly, a unique adult day health program.

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H9001_2012_720_18_r2 CMS Approved 12292011

The information on this page was last updated on 12/6/2011

Call us toll-free at 1-888-340-5504 (TTY users please call TRS Relay 711), Monday through Friday, 8 a.m. to 8 p.m. (From October 15 through February 14, we're available seven days a week.)

Other resources and tools

Medicare Part D online forms