Member Materials and Forms — 2021
On this page, you can find important documents related to your Senior Whole Health of Massachusetts health plan. Click the links below to download each document.
Annual Materials 2021
Summary of Benefits: A summary of what we cover and what you get from Senior Whole Health. For a complete list of covered services and exclusions, refer to your Evidence of Coverage.
Summary of Benefits Addendum: For SCO (MassHealth Medicaid only) members, this document provides additional information.
Evidence of Coverage (EOC): Your member handbook, or EOC, gives you detailed information about your benefits and services, and all the information you need on working with Senior Whole Health.
(SCO) EOC Addendum: For SCO (MassHealth Medicaid only) members, this document provides additional information.
Part D Formulary: This lists all of the drugs that we cover. The drugs on the formulary are selected by our plan with the help of a team of health care providers.
SCO Formulary: This lists all of the drugs that we cover in our SCO plan. The drugs on the formulary are selected by our plan with the help of a team of health care providers.
Annual Notice of Changes: Describes changes to your SWH plan coverage, costs or service area.
LIS Rider: Describes the extra help you get paying for your prescription drugs.
LIS Premium Summary: This chart will show you what your monthly premium will be if you get extra help from Medicare to help pay for your Medicare prescription drug plan costs.
Pharmacy & Prescription Drug Materials
Provider and Pharmacy Directories
A list of network providers and pharmacies you may use to get care, services and prescription drugs.
Other Member Materials
2021 Medicare Star Ratings: The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality rating system to measure the experiences Medicare beneficiaries have with their health plan.
Behavioral Health Services
Over-The-Counter (OTC) and Additional Coverage Drug List
Frequently Used Forms
Appointment of Representative Form
Health Care Proxy Form
Prescription Coverage Determination Form (PDF)
Prescription Coverage Determination
Medicare Reconsideration Request Form
Medicare Redetermination Request Form