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Mass General Brigham SCO and One Care forms and documents

Find resources to help you use your plan and benefits.

Plan documents

Member handbook: English | Spanish (Updated 10/1/27)
Otherwise known as the Evidence of Coverage. Information to help you use your plan benefits.

Summary of benefits: English | Spanish (Updated 10/1/27)
A summary of what we cover.

Medicare Star Ratings: English | Spanish
The Star Rating of this plan. You can use the Star Rating to see how different plans compare to one another.

Member handbook: English | Spanish (Updated 10/1/27)
Otherwise known as the Evidence of Coverage. Information to help you use your plan benefits.

Summary of benefits: English | Spanish (Updated 10/1/27)
A summary of what we cover.

Medicare Star Ratings: English | Spanish
The Star Rating of this plan. You can use the Star Rating to see how different plans compare to one another.

MassHealth resources

My Ombudsman will work with you to make sure you receive your benefits and exercise your rights within your health plan.

Phone: 855-781-9898 (Toll Free). For TTY users, use MassRelay at 711 to call the number above. 

Email: info@myombudsman.org

Website: myombudsman.org

Each state has a government program with trained counselors to help you with health insurance needs. These programs are called SHIP, or State Health Insurance Assistance Program. In Massachusetts, the SHIP is called SHINE. The program is not connected with Mass General Brigham Health Plan or any insurance company.

You can learn more about SHIP on their website at https://www.shiphelp.org/.

Serving the Health Insurance Needs of Everyone (SHINE)

The SHINE Program provides free health insurance information, counseling, and assistance to people who are eligible for Medicare and their caregivers. 

A SHINE counselor will help you:  

  • Understand your Medicare and other health insurance and drug coverage options 
  • Find the right coverage for you  
  • Find ways you can save money on your prescription drugs and health insurance  
  • Help you apply for programs that will lower your costs  
  • Provide information to help you make the best coverage selection  

You can contact a SHINE Counselor through the phone number or email below.

Phone:
Call MassOptions at 800-243-4636
TTY/ASCll 800-439-2370 

Email: SHINE@state.ma.us

If you have questions about the benefits included with MassHealth, you can contact their Customer Service team.

Phone: 800-841-2900 (TTY users should call  800-497-4648)

Hours: Monday through Friday, 8 a.m. to 5 p.m.

Website: mass.gov/MassHealth

Additional resources

These resources explain how we define services that are medically necessary.

Explore all medical necessity criteria and guidelines:

Medical Necessity Criteria

View medical necessity criteria and guidelines from Mass General Brigham Health Plan.

First time users will be asked to create a One Healthcare ID account. Please enter your name and email address and accept the InterQual End User License Agreement to continue. You will then be redirected to our partner website for medical necessity criteria information.

These resources explain how to verify prescription drug coverage and how to submit requests and authorizations for medication.

Explore all drug coverage forms and resources:

OptumRx Mail Service Order Form (PDF)
OptumRx Medicare Part D Prescription Claim Form (PDF) English | Spanish

Coverage determination requests

SCO Medicare Prescription Drug Coverage Determination Request Form (PDF) 
 One Care Medicare Prescription Drug Coverage Determination Request Form (PDF) 

Organization determination requests

SCO Part B Prescription Medical Drug Organization Determination Request Form (PDF) 
One Care Part B Prescription Medical Drug Organization Determination Request Form (PDF) 

Use these forms to enroll in a plan with us or review your rights and responsibilities if you want to change plans.

Mass General Brigham One Care Individual Enrollment Application (PDF)

Mass General Brigham SCO Individual Enrollment Application (PDF)

Reimbursement forms

Use these forms to request reimbursements for qualifying healthcare expenses.

Medical Reimbursement Request Form (PDF) English | Spanish

Behavioral Health Reimbursement Request Form (PDF) English | Spanish

SCO Flexible Benefit Card Reimbursement Form (PDF) English | Spanish

SCO Fitness Reimbursement Form (PDF) English | Spanish

Wig Reimbursement Request Form and Instructions (PDF) English | Spanish

 

Vision reimbursement form

EyeMed Out of Network Reimbursement Form (PDF)

 

Order forms

Use these forms to order products and prescriptions via mail.

OptumRx Mail Service Order Form (PDF)

Over-the-counter (OTC) product order form (PDF) English | Spanish

Use this form to give a friend, relative, doctor, or other person the right to legally represent you for healthcare coverage decisions.



If you would like a friend, relative, doctor, or other person to act for you as your “representative” to ask for a coverage decision (such as whether a service is covered) or make an appeal, you may need to appoint them as your representative. If that person is already legally authorized to act as your representative under state law, you do not need to appoint them to represent you. If you want to appoint someone to be your representative, complete the “Appointment of Representative” form (PDF) English | Spanish. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give Mass General Brigham Health Plan a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.

Authorizations

Request For Service Coverage Determination (PDF) Coming soon
This form can be used to submit information to Mass General Brigham Health Plan to help determine if a service or Part B Medical service drug is covered.

Use these documents for help with disaster relief or to file a grievance or make an appeal.

Grievances and Appeals (PDF)

Getting Care During a Disaster (PDF)

Please use this form (PDF) English | Spanish to request copies of your protected health information contained within the designated record set maintained by Mass General Brigham Health Plan.

If you would like to connect your health data to a selection of third-party mobile apps, you can do so by creating an account on our secure app connection platform.
Learn how to create your account and connect your health data.

Mass General Brigham SCO (Senior Care Options) is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Mass General Brigham One Care is a health plan that contracts with both Medicare and MassHealth (Medicaid) to provide benefits of both programs to enrollees. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

Medicare Advantage plans About Senior Care Options (SCO) plan Contact us One Care Plan

© 2026 Mass General Brigham Health Plan, Inc.

Mass General Brigham Health Plan is an HMO-POS/PPO organization with a Medicare contract. Enrollment in Mass General Brigham Health Plan depends on contract renewal. Other providers/pharmacies are included in our network.
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Mass General Brigham One Care is a Dual Special Needs Plan (D-SNP) that contracts with both Medicare and MassHealth (Medicaid) to provide benefits of both programs to enrollees. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone age 21 - 64 who qualifies for MassHealth Standard or CommonHealth and Original Medicare and does not have any other comprehensive health insurance, except Medicare.
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Mass General Brigham SCO (Senior Care Options) is a Dual Special Needs Plan (D-SNP) with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plan’s contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare and does not have any other comprehensive health insurance, except Medicare.
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Last updated: 10/1/2025

Report a compliance issue Medicare complaint website Non-discrimination notice Disclaimer, privacy, and security Notice of privacy practices Web accessibility statement Medicare Advantage multi-language interpreter services SCO and One Care multi-language interpreter services SCO non-discrimination notice English | Spanish One Care non-discrimination notice English | Spanish