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Forms

Below are a list of forms for Health New England Medicare Advantage members. The forms contain instructions on how to fill them out and submit back to Health New England. You can download and print the form you need by clicking on the form name below.

Health New England offers various allowance programs as part of our additional benefits. As a Medicare Advantage member, you are eligible to be reimbursed for the following:
  • $150 per calendar year for joining a Fitness, Weight Watchers, Acupuncture, Over-the-Counter Items, Activity/Fitness Tracker.
  • $250 per calendar year for any Dental Services with any dental provider
  • $100 every two calendar years for prescription eye wear
  • $350 per year for a wig if you are on or recently undergone chemotherapy

2018 Additional Benefits >     2019 Additional Benefits >
Mail Order is a convenient and cost-effective way for you to order a 90-day supply of medication for delivery to your home, office or location of your choosing. You will minimize trips to the pharmacy and save money on your prescriptions. Health New England is pleased to offer you access to two mail order pharmacies.

To get your prescription drugs through one of Health New England’s mail order programs, please complete one of the mail order forms below and mail it with your prescription directly to the address below. Please make sure to include your member ID number along with your date of birth on your prescriptions. (Note: If you need your medication right away, ask your doctor to write two prescriptions. Fill the first one at your local drug store and mail the second one to the mail order pharmacy.)

OptumRx Home Delivery          WellDyneRx
P.O. Box 2975 
Mission, KS 66201        


Phone: (800) 763-0044
TTY: (888) 206-8041
Fax: (800) 893-2299

Optum Mail Order Form

Hours of Operations:
Monday-Friday, 8 a.m. - 8 p.m.
      P.O. Box 166
Lakeland, FL 33804-0369


Phone: 888.479.2000
TTY: 800.900.6570
Fax: 877.221.1259
Web: WellDyneRx Online
WellDyneRX Mail Order Form

Hours of Operations:
24 hours a day, 7 days a week

When a new prescription is received by WelldyneRX or Optum Home Delivery, it may take 10-14 business days (including processing of the prescription) for the prescription to reach your home. For prescription refills it may take 7-10 business days for the prescription refill to reach your home. If your mail order drugs do not arrive within those estimated times, please call WelldyneRX member services at (888) 479-2000, or Optum Home Delivery member services at (800) 577-6552. Both mail order services are available 24 hours, 7 days a week.



The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This information is not a complete description of benefits. Call (413) 787-0010 or TTY 711.

H8578_2018_049 Accepted
 last updated on 10/1/2018