Prescription Advantage Documents and Resources

Need Help? If consumers have questions about the Prescription Advantage Program, call MassOptions at 1-800-243-4636 and select Option 3; TTY: 711

Member Forms

Prescription Drug Reimbursement Form — Non-Medicare Members 
Use this form to request reimbursement for prescription drug costs paid out of pocket. 
Download form 

Self-Attestation of Income Change — Existing Member 
Use this form to report income changes that may affect eligibility or membership category. 
Download form 

Representative Authorization Form 
Use this form to authorize someone to act on your behalf or receive information about your benefits. 
Download form

Rate Schedules

Members Eligible for Medicare or Other Drug Coverage 
Income eligibility and benefit information for members with Medicare or other drug coverage. 
Download English rate schedule 
Download Spanish rate schedule 

Members Not Eligible for Medicare or Other Drug Coverage 
Income eligibility, copayments, deductibles, and reimbursement information. 
Download English rate schedule 
Download Spanish rate schedule 

Helpful Resources

Find contact information for SHINE, Medicare, MCPHS Pharmacy Outreach, and MassHealth Customer Service. 
Download helpful resources