eternalHealth Massachusetts Plan Documents

Personal Forms

We have forms to make every part of your Medicare journey quick and easy. From enrollment forms, the appointment of representative forms, ACH forms, and more

Authorization for Disclosure of Protected Health Information 

Complete and return this form when you would like us to share your health information.

• Authorization for Disclosure of Protected Health Information
• Autorización para la Divulgación de Información de Salud Protegida

Appointment of Representative Form

Complete and return this form when you would like to appoint a representative to act on. your behalf during the appeal process.

• Appointment of Representative Form

Advance Directives Information

Complete this legal document that explains how you want medical decisions made about you if you are unable to make the decisions yourself.

• Advance Directive Information

Prior Authorizations, Appeals, and Grievances Information

Learn more on how to file a prior auth, appeal, or grievance.

• Prior Authorizations, Appeals, and Grievances Information

Plan Forms

Enrollment Form

Complete a paper enrollment form and submit your application for an eternalHealth Medicare Advantage Plan

• 2025 Enrollment Form
• 2025 Formulario de inscripción

• 2024 Formulario de inscripción

Disenrollment Form

Medicare members are allowed to disenroll from their plan during specific periods throughout the year as specified by CMS (Centers for Medicare and Medicaid). Learn more about disenrollment here.

• Disenrollment Form

ACH Form

Pay your monthly eternalHealth Medicare Advantage premiums quickly and easily

• ACH Form
• Formulario ACH

Direct Member Reimbursement Form

Complete and return this form to get paid back for medical services or medications that you paid for
yourself.

• Direct Member Reimbursement Form
• Formulario de reembolso directo para miembros

Referral Form for American Specialty Health

Need to see a specialist for rehabilitation services, physical therapy, occupational therapy, speech therapy, acupuncture, or chiropractic services? Have your Primary Care Provider (PCP) submit the referral form.

• Referral Form for American Specialty Health

Request for Redetermination of Medical Services and Products

If you were denied medical services or products and would like a redetermination, please complete this form.

• Request for Redetermination of Medical Services and Products

Member Complaint Form

We take your concerns seriously – please complete the attached form for any complaints.

• Member Complaint Form
• Formulario de quejas de miembros

Summary of Benefits (SoB)

See below for the Summary of Benefits for each of eternalHealth’s Medicare Advantage Plans.

2025 eternalHealth Summary of Benefits

Click your plan’s name below to access its related Summary of Benefits (SOB) for 2025:

• 2025 eternalHealth Forever HMO (Last updated December 10th, 2024)
• 2025 eternalHealth Freedom PPO (Last updated December 10th, 2024)
• 2025 eternalHealth Give Back PPO (Last updated December 10th, 2024)
• 2025 eternalHealth Forever HMO (Última actualización el 29 de agosto de 2024)
• 2025 eternalHealth Freedom PPO (Última actualización el 29 de agosto de 2024)
• 2025 eternalHealth Give Back PPO (Última actualización el 29 de agosto de 2024)

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Evidence of Coverage (EoC)

See below for the Evidence of Coverage for each of eternalHealth’s  Medicare Advantage Plans.

eternalHealth Evidence of Coverages

Your Evidence of Coverage will provide you with detailed information on anything you may need to know, including what your plan covers, what your payments will look like, how you can communicate with eternalHealth and other local Medicare resources, and your rights and responsibilities as a member.

Click your plan’s name below to access its related Evidence of Coverage (EOC) for 2025:

• 2025 eternalHealth Forever HMO (Last updated April 22nd, 2025)
• 2025 eternalHealth Freedom PPO (Last updated April 22nd, 2025)
• 2025 eternalHealth Give Back PPO (Last updated April 22nd, 2025)

Annual Notice of Change (ANoC)

See how your plan will change in the coming year.

2025 eternalHealth Annual Notice of Changes

Click your plan’s name below to access its related Annual Notice of Change (ANoC) for 2025:

• 2025 eternalHealth Forever HMO (Last updated August 23, 2024)
• 2025 eternalHealth ForeverMore HMO (Last updated August 23, 2024)
• 2025 eternalHealth Freedom PPO (Last updated August 23, 2024)
• 2025 eternalHealth Give Back PPO (Last updated August 23, 2024)
• 2025 eternalHealth Forever HMO (Última actualización el 23 de agosto de 2024)
• 2025 eternalHealth ForeverMore HMO (Última actualización el 23 de agosto de 2024)
• 2025 eternalHealth Freedom PPO (Última actualización el 23 de agosto de 2024)
• 2025 EternalHealth Give Back PPO (Última actualización el 23 de agosto de 2024)

Formulary

A formulary is a list of generic and brand name prescription drugs that are covered under your health plan.

2025 Formulary 

Access the 2025 formulary for the following plans.

• eternalHealth Forever HMO
• eternalHealth Freedom PPO
• eternalHealth Give Back PPO

You can find detailed information about eternalHealth’s prescription drug benefits here.

Over-the-Counter (OTC), Healthy Grocery*, & Dental

Navigate to Nation’s Benefits Member Portal HERE

eternalHealth is excited to offer the OTC and Healthy Grocery Mastercard® Prepaid Flex Card through Nations Benefits! View the catalogs below and be sure to access your member portal to order your OTC and Healthy Grocery* items, check your OTC & Dental balances, and more!

• View 2025 OTC & *Healthy Grocery Catalog 
• View 2025 OTC & *Healthy Grocery Catalog 
• View 2024 OTC Catalog
• View 2024 *Healthy Grocery Catalog

*The healthy grocery benefit is a special supplemental benefit available only to members with eligible chronic health conditions. Not all members will qualify.  

Part D – Prescription Drug Forms

Request for Medicare Prescription Drug Coverage Determination

This form will allow you to determine your coverage of a prescription drug.

• Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination Of Medicare Prescription Drug Denial

You may appeal a coverage determination about a prescription drug with this form.

• Request For Redetermination Of Medicare Prescription Drug Denial

Part D Late Enrollment Penalty (LEP) Reconsideration Request Form

Use this form to request a reconsideration for the elimination of your Part D Late Enrollment Penalty.

• LEP Reconsideration Request Form

eternalHealth Arizona Plan Documents

Personal Forms

We have forms to make every part of your Medicare journey quick and easy. From enrollment forms, the appointment of representative forms, ACH forms, and more!

Authorization for Disclosure of Protected Health Information

Complete and return this form when you would like us to share your health information

• Authorization for Disclosure of Protected Health Information
• Autorización para la Divulgación de Información de Salud Protegida

Appointment of Representative Form

Complete and return this form when you would like to appoint a representative to act on your behalf during the appeal process.

• Appointment of Representative Form

Advance Directives Information

Complete this legal document that explains how you want medical decisions made about you if you are unable to make the decisions yourself.

• Advance Directive Information for Arizona

Prior Authorizations, Appeals, and Grievances Information

Learn more on how to file a prior auth, appeal, or grievance.

• Prior Authorizations, Appeals, and Grievances Information

Plan Forms

Enrollment Form

• 2025 Enrollment Form
• 2025 Formulario de inscripción

Disenrollment Form

Medicare members are allowed to disenroll from their plan during specific periods throughout the year as specified by CMS (Centers for Medicare and Medicaid).

• Disenrollment Form

ACH Form

Pay your monthly eternalHealth Medicare Advantage premiums quickly and easily

• ACH Form
• Formulario ACH

Direct Member Reimbursement Form

Complete and return this form to get paid back for medical services or medications that you paid for yourself.

• Direct Member Reimbursement Form
• Formulario de reembolso directo para miembros

Referral Form

Need to see a specialist? Have your Primary Care Provider (PCP) submit the referral form.

• Referral Request Form
• Formulario de solicitud de referencia

Referral Form for American Specialty Health

Need to see a specialist for rehabilitation services? Have your Primary Care Provider (PCP) submit the referral form.

• Referral Form for American Speciality Health

Request for Redetermination or Medical Services and Products

If you were denied Medical services or products and would like a redetermination, please complete this form.

• Request for Redetermination or Medical Services and Products

Member Complaint Form 

We take your concerns seriously – please complete the attached form for any complaints.

• Member Complaint Form
• Formulario de quejas de miembros

Summary of Benefits (SoB)

See below for the Summary of Benefits for eternalHealth’s  Medicare Advantage Plans for 2025

• 2025 eternalHealth Horizon HMO (Last updated December 10th, 2024)
• 2025 eternalHealth Grand Give Back HMO (Last updated December 10th, 2024)
• 2025 eternalHealth Valor Give Back HMO-POS (Last updated December 10th, 2024)
• 2025 eternalHealth Horizon HMO (Última actualización el 29 de agosto de 2024)
• 2025 eternalHealth Grand Give Back- HMO (Última actualización el 29 de agosto de 2024)
• 2025 eternalHealth Valor HMO-POS (Última actualización el 29 de agosto de 2024)

Evidence of Coverage (EoC)

Your Evidence of Coverage will provide you with detailed information of anything you may need to know, including what your plan covers, what your payments will look like, how you can communicate with eternalHealth and other local Medicare resources, to your rights and responsibilities as a member.

Click your plan’s name below to access its related Evidence of Coverage (EOC) for 2025:

• 2025 eternalHealth Horizon HMO (Last Updated April 22nd, 2025)
• 2025 eternalHealth Grand Give Back HMO (Last Updated April 22nd, 2025)
• 2025 eternalHealth Valor Give Back HMO-POS (Last Updated April 22nd, 2025)

Formulary

A formulary is a list of generic and brand name prescription drugs that are covered under your health plan.

2025 Formulary 

Access the 2025 formulary for the following plans.

• eternalHealth Horizon HMO
• eternalHealth Grand Give Back HMO

Over-the-Counter (OTC), *Healthy Grocery, & Dental

Navigate to Nation’s Benefits Member Portal HERE

eternalHealth is excited to offer the OTC and Healthy Grocery Mastercard® Prepaid Flex Card through Nations Benefits! View the catalogs below and be sure to access your member portal to order your OTC and Healthy Grocery* items, check your OTC & Dental balances, and more!

• View 2025 OTC & *Healthy Grocery Catalog 
• View 2025 OTC & *Healthy Grocery Catalog (Effective 1/1/2025)

*The healthy grocery benefit is a special supplemental benefit available only to members with eligible chronic health conditions. Not all members will qualify.  

 

Part D – Prescription Drug Forms

Request for Medicare Prescription Drug Coverage Determination

This form will allow you to determine your coverage of a prescription drug.

• Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination Of Medicare Prescription Drug Denial

You may appeal a coverage determination about a prescription drug with this form.

• Request for Redetermination for Medicare Prescription Drug Denial

Part D Late Enrollment Penalty (LEP) Reconsideration Request Form

Use this form to request a reconsideration for the elimination of your Part D Late Enrollment Penalty.

• LEP Reconsideration Request Form