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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.
Forget Your Card?
If you forget your card, your provider does not accept Mastercard, or if you had difficulties swiping your card, you can submit a claim for reimbursement. Reimbursement requests can be submitted via Member Portal, mobile application or paper.
To download a Medicare Advantage reimbursement request form, click here.
Click here to access the 2022 reimbursement form (only valid for 2022 purchases)
If you would like to appoint someone to represent you in requesting an initial organization or coverage determination or in filing a grievance or appeal, please fill out the CMS Appointment of Representative Form and return to us at the address below.
You may revoke an authorization or end an appointment at any time by sending us a letter to the address below. Please include your name, address, member identification number and a telephone number where we can reach you.
Completed forms may be mailed to the address below or faxed to (413) 233-2685
Health New England
Attention: Complaints & Appeals
One Monarch Place, Suite 1500
Springfield, MA 01144-1500
If you prefer to pay by automatic withdrawal from checking or savings account, known as electronic funds transfer (EFT), please fill out the EFT form and return to us by fax (413) 233-2730 or mail it to this address:
2024 Enrollment Form: Hampden & Hampshire Counties
2024 Enrollment Form: Berkshire & Franklin Counties
2024 Enrollment Instructions
2023 Enrollment Form
2023 Enrollment Instructions
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.)
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.
Group Medicare Supplement plans are eligible for $250 reimbursement per calendar year. Medicare Supplement 1 and 1A plans are eligible for $150 reimbursement per calendar year. Eligible items include:
Click here to download the Wig Reimbursement Form.
Last updated: 10/1/23