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 links below.


To help you make healthy and important lifestyle choices more easily, Health New England is introducing a new Medicare Advantage Additional Benefits Card. Click here to learn more.

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.

You can make your own personal health care plan using this Getting Started Toolkit. This step-by-step tool kit provides Massachusetts-based health care planning information, documents, and discussion guides to start to make a personal plan and put your plan into action. For more information visit  www.honoringchoicesmass.com.

We all need a little help sometimes. A personal representative is someone who is authorized to contact Health New England and discuss your personal health information on your behalf. If you would like to name a personal representative, please fill out the form and return to us at the address below.

Health New England - Medicare Advantage Plan
Enrollment Department
One Monarch Place
Springfield, MA 01144-1500

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.

Please provide a written description of your complaint. Please include names and dates whenever possible. If necessary you may attach a separate sheet to this form.

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

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At Health New England, we try to be as flexible as possible in how we accept payments. You can elect to pay by automatic withdrawal from Social Security or by check or money order (payable to: Health New England Inc., P.O. Box 415425, Boston, MA 02241-5425).

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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:

Health New England Revenue Management and Recovery
One Monarch Place
Suite 1500
Springfield, MA 01144-1500

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.

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:

  • Acupuncture
  • Aerobic/wellness classes & apps
  • Athletic event registration fees
  • Bike shares
  • Community supported agriculture (CSA) or farm shares
  • Fitness equipment (i.e., treadmill, workout videos)
  • Golf and ski tickets
  • Nutrition classes & apps
  • Mindfulness classes & apps
  • Personal trainer fees Qualifying fitness club memberships School and town sports Weight Watchers®


    • Access 2025 Form

    Click here to download the Wig Reimbursement Form.

    HNE

    Last updated: 10/1/24