Forms - Prescription Advantage - Massachusetts State

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Prescription Advantage is a state-sponsored prescription drug program administered by the Commonwealth of Massachusetts Executive Office of Elder Affairs for seniors and people with disabilities.

Forms

Material Request Form

Community Meeting Request Form

Paper Claim Form for Medicare members

Paper Claim Form for Non Medicare members

Mail Order Prescription Form for members only

Prescription Advantage Non Medicare Fact Sheet

Prescription Advantage Medicare Fact Sheet

Helpful Resources

Instructions for Online Application Only

Non Medicare Prescription Value Guide

Prescription Advantage Disability Status Documentation

Prescription Advantage Income Documentation

Self-Attestation New Applicant

Self-Attestation Income to be Added

Self-Attestation Income Changes Existing Member

Prescription Advantage Application Material (Paper)

Application Form

Overview and Instructions

Prescription Advantage Rate Schedule Guide for Members Eligible for Medicare

Prescription Advantage Rate Schedule Guide for Members Not Eligible for Medicare

Representative Authorization Forms

Instrucciones para la solicitud de Prescription Advantage en línea

Formulario de solictude de Prescription Advantage

Tabla de trifas de Prescription Advantage para miembros elegibles para Medicare u otra cobertura de medicamentos

Please note: If you need assistance with any of these documents in any other language, please call our customer service line at 800-243-4636 for translation assistance.