Member Resources

Automatic Payment Options Form [PDF]
Use this form to sign up for automatic payment of your monthly plan premium.

Appointment of Representative Form (CMS-1696) [PDF]
Use this form to appoint a representative who has legal authority to act on your behalf in Medicare claims, appeals, grievances, or requests.

Blood Pressure Log [PDF]
Use this log to record daily blood pressure and heart rate readings and share with your doctor to support ongoing care.

Continuity of Care Form [PDF]
Use this form to request a 90-day Continuity of Care period to ensure your ongoing care remains uninterrupted.

Members Rights and Responsibilities Statement [PDF]
This document provides the Martin's Point Health Plan Member Rights and Responsibilities statement.

Multi-language Interpreter Services [PDF]
This document provides information for multi-language interpreter services.

Permission to Speak With Others [PDF]
Use this form to authorize Member Services to share certain aspects of your health care or payment with a designated representative for discussion purposes only.

Preventive Care Checklist [PDF]
Use this form to track your recommended preventive care and bring it with you to your next primary care visit.

Provider Attestation for Supplemental Benefits Form [PDF]
Use this form to receive supplemental benefits for specific diagnosis.

Request for Medicare Prescription Drug Coverage Determination [PDF]
Use this form to request coverage for a drug that isn’t covered or has restrictions.

Request for Redetermination of Medicare Prescription Drug Denial [PDF]
Use this form to request to appeal a denied prescription coverage.

Residence Address Verification Form [PDF]
Use this form to verify your residence address.

Waiver of Liability [PDF]
Use this form to waive any right to collect payment for services for which payment has been denied.

Veterans Affairs Record Release form [PDF]
Use this form to authorize the Department of Veterans Affairs to release specific health information to designated individuals or organizations.

The Evidence of Coverage document provides the details of your Medicare health benefits, services, and prescription drug coverage as a member of Martin's Point Generations Advantage from January 1 – December 31, 2025. It explains how to get coverage for the health care services and prescription drugs you need.

Prime (HMO-POS)

Evidence of Coverage—Prime H5591-015-001 [PDF]
Maine Counties: Lincoln, Oxford, Piscataquis, Somerset, Waldo | New Hampshire Counties: Belknap, Carroll, Coos Grafton

Evidence of Coverage—Prime H5591-015-002 [PDF]
Maine Counties: Aroostook, Franklin, Hancock, Knox, Penobscot Washington

Evidence of Coverage—Prime H5591-005 [PDF]
New Hampshire Counties: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, Sullivan

Evidence of Coverage—Prime H5591-006-001 [PDF]
Maine Counties: Cumberland and York

Evidence of Coverage—Prime H5591-006-002 [PDF]
Maine Counties: Androscoggin, Kennebec, Sagadahoc

Alliance (HMO)

Evidence of Coverage—Alliance H5591-003 [PDF]
All Counties in Maine and New Hampshire

Value Plus (HMO-POS)

Evidence of Coverage—Value Plus H5591-009 [PDF]
All Maine Counties

Select (LPPO)

Evidence of Coverage—Select H1365-001 [PDF]
Maine Counties: Androscoggin, Aroostook, Cumberland, Franklin, Hancock, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, Washington, York | New Hampshire Counties: Cheshire, Coos, Hillsborough, Merrimack, Rockingham, Strafford, Sullivan

Access (LPPO)

Evidence of Coverage—Access H1365-004-002 [PDF]
New Hampshire Counties: Belknap, Carroll, Coos, Grafton

Evidence of Coverage—Access H1365-004-003 [PDF]
New Hampshire Counties: Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, Sullivan

This is a summary of drug and health services covered under your Martin's Point Generations Advantage plan.

Summary of Benefits [PDF]
All Plans: Prime (HMO-POS), Select (LPPO), Access (LPPO), Value Plus (HMO), Alliance (HMO)

Wellness Wallet and Eyewear Reimbursement Request

To be eligible for payment, the date of service or purchase must be in 2025 and you must submit your claim by April 30, 2026. 

Online Reimbursement: Try this new option for easier submission and quicker processing!

Submit Online Reimbursement Request

Reimbursement by Mail: Use this form for items/services covered under your 2025 Wellness Wallet or Eyewear reimbursement benefit up to your plan’s annual limit. 

2025 Member Reimbursement Form Wellness Wallet/Eyewear [PDF]

Note: DO NOT use the above form if your Eyewear purchase is due to recent cataract surgery. In this case, use the Medical Services Reimbursement Form seen below. 

Medical Services Reimbursement Request

This form is for reimbursement for covered medical services that you received through a provider or at a medical facility. This also includes eyewear that you purchased due to recent cataract surgery.

Medical Services Reimbursement Form [PDF]

Prescription Drug Reimbursement Request

Use this form when you have paid out-of-pocket for your Part D formulary prescription drug. DO NOT use any other forms if your reimbursement request is for prescription drugs. 

Prescription Drug Reimbursement Form [PDF]

Get your health care journey off to a great start. Take your Health Risk Assessment—an online questionnaire to help you understand your health/health risks, and guide you toward being as healthy as possible.

How to Take Your Health Risk Assessment (HRA)

To take the HRA (at no additional charge) you must first have an online portal account. Log in with your portal username and password or click “Register” if this is your first time logging in. When prompted, enter your Generations Advantage member ID number and follow the instructions. This website will allow only you to see your results anytime.

If you don’t have internet access or have questions, call us at 1-877-659-2403 (TTY: 711) and leave a message. We will return your call within two business days.

You can find the Health Risk Assessment here:

Your free* annual flu shots can be administered at participating pharmacies** as well as by your primary care provider. Shots covered include quadrivalent, trivalent, trivalent (high dose), and intradermal.

• In-Network Pharmacy: Free at participating pharmacies including Hannaford, Rite Aid, CVS (including former Target pharmacies), Shaw’s/Osco, Walgreens, and Walmart.

• PCP/Doctor's Office: If you get the shot at your primary care provider’s office, you may have to pay a copayment for the office visit depending on your plan, but there will be no cost for the flu shot.

• Out-of-Network Pharmacy: If you get your flu shot at a pharmacy that is not in the Vaccine Pharmacy Network, it may still be covered by your plan. You will pay the full cost at the pharmacy and submit a form to us for reimbursement.

If you don’t show your Generations Advantage member ID card when you get your flu shot, you will pay the full cost at the pharmacy and submit a form to us for reimbursement.

Flu Shot Reimbursement Form [PDF]

If your pharmacist has problems sending your claim to us, they should call our Part D Pharmacy Help Desk at 1-800-364-6331.

*Influenza (flu) vaccines are covered under your Medicare Part B benefit through your Generations Advantage plan.

**The Vaccine Pharmacy Network is offered through our relationship with our pharmacy benefit manager, CVS Caremark. Pharmacy network may change on January 1 of each year. Other pharmacies are available in our network.

For detailed coverage information, visit:

The Part B Step Therapy requirement encourages members to try less costly but usually just as effective ‘preferred’ drugs before the plan covers another ‘preferred’ drug. For example, if Drug A (preferred) and Drug B (non-preferred) treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for the member, the plan will then cover Drug B.

Step therapy is not required for members who have used a non-preferred drug within the last 365 days, but authorization is required. To see list of preferred and non-preferred step therapy drugs please see:

2025 Part B Step Therapy Drug List [PDF]

Colorectal cancer screenings save lives. All screenings have a $0 copay when you go to an in-network provider. Ask your primary care provider which screening and schedule is right for you. We cover these screenings more frequently for people at high risk for colorectal cancer.

For detailed coverage information, refer to your Evidence of Coverage document:

As a Martin’s Point Generations Advantage member, you are eligible to receive free, personalized care management.

Our care managers can help you:

• Manage your health care

• Navigate your health plan

• Understand medications

• Find community support and resources

Sign up for a dedicated medical or behavioral health care manager who will help you succeed at leading a healthy, active, and full life.

Martin’s Point care management programs are entirely voluntary. You can choose not to participate or to stop participating in the program at any time. If you have immediate concerns regarding your health, please contact your doctor. Always consult your health care provider before making any lifestyle changes. Only your doctor can diagnose and treat a medical condition.

For detailed coverage information, visit:

At Martin's Point, we’ve partnered with LifeStation to offer peace of mind and security through advanced medical alert devices. Whether you’re eligible for our Covered Medical Benefit (Alliance plan members only) or looking to take advantage of our value-added discount (available to all other plan members), LifeStation ensures you're always connected when it matters most.

Covered Medical Benefit (Alliance Members Only)

For Martin's Point Generations Advantage Alliance plan members, this benefit offers fully covered medical alert devices. You'll receive 24/7 monitoring with no out-of-pocket costs for shipping, activation, or monthly fees (valued at $13.95–$18.95 per month). Covered devices include:

• In-home landline system
• In-home cellular system
• In-home cellular system with fall detection
• Mobile unit with GPS/Wi-Fi
• Mobile unit with GPS/Wi-Fi and fall detection

Spousal coverage and product warranties are also included at no additional charge.

How to Use Your Covered Medical Benefit:

1. Dedicated web page: LifeStation Medical Alert - Martin's Point
2. Call to enroll: 1-866-220-0934
   Speak directly with a LifeStation representative to enroll—be sure to have your Generations Advantage Member ID ready.

What’s Covered:

• Shipping and activation fees
• Monthly device and monitoring fees
• Spousal coverage for in-home devices
• Product warranties
• Note: Optional accessories, including a smartwatch, are not included.

Medical Alert Device Discount

Generations Advantage plan members (Access, Select, Prime, and Value Plus) receive 25% discounts on medical alert devices through LifeStation. Please note, this is a value-added discount, not a covered plan benefit.

How to Use Your Value-Added Discount:

1. Dedicated web page: LifeStation Medical Alert - Martin's Point
2. Call to enroll: 1-855-793-8555
   Speak directly with a LifeStation representative to enroll—no Generations Advantage ID required. 
3. Payment information needed: Provide a credit card or bank account for automatic deductions of monthly charges for the device and monitoring.

What’s Covered:

• Shipping and activation fees
• Monthly charges for device and monitoring
• Note: Optional accessories, including a smartwatch, can be offered at additional rates.

Devices & Pricing:

• In-home landline: $19.95/month
• In-home cellular: $25.95/month
• Mobile unit with GPS/WiFi: $29.95/month
• Fall detection (optional add-on): $5.00/month
  
   

Once enrolled in either option, LifeStation® makes it easy to manage your service and get support when you need it. Call LifeStation® Customer Service at 1-800-998-2400 for troubleshooting or to explore device add-ons.

Eligible members have the option to purchase nutritionally balanced, refrigerated, and ready-to-eat meals that are delivered by Mom’s Meals directly to your home.

• Martin’s Point Generations Advantage members will get free shipping on all orders (a savings of $14.95).
• Menus are designed by chefs and registered dietitians to support general wellness goals or the specific nutrition needs of common health conditions.
• Members can select every meal, every order from over 70 entrée options.
• Entrées are refrigerated and ready-to-eat after just two minutes in the microwave.

Benefit Details

Eligibility: This is available for plan members with congestive heart failure (CHF) or end-stage renal disease (ESRD) post-discharge or post-surgery, or for members with CHF or ESRD who indicate need and meet objective screening criteria.

• Up to 7 days (14 meals) of coverage for each qualifying event (post-discharge, post-surgery, or need identified by the plan).
• Up to an additional 7 days (14 meals) of coverage when extended need and high risk is identified by the plan.

Alliance (HMO) Plan Members: In addition, Alliance members have a separate meal benefit:

• Up to 3 weeks (42 meals) per inpatient stay or surgery.
• Up to 1 week (14 meals) per year for members with chronic conditions (such as diabetes mellitus (DM) or chronic obstructive pulmonary disease (COPD)) as part of a supervised program to transition into lifestyle modifications.

Place your order online or by phone using code MPGA to activate the offer:

Online: MomsMeals.com/MPGA
Phone: 1-877-347-3438

Gain insight into how we determine the medical necessity for treatments and services, ensuring you receive care that meets established medical standards. This knowledge supports your health care journey with us, aligning with Medicare's guidelines.

For detailed clinical coverage criteria, visit:

What is the Maximum Out-of-Pocket limit?

Your Maximum Out-of-Pocket limit is the most you will pay for covered medical services in a fiscal year. Once you reach your Maximum Out-of-Pocket limit, you will no longer pay cost shares for those services. Here’s what you need to know:

How do I know if I’ve reached my Maximum Out-of-Pocket limit?

To check if you’ve hit your limit, contact Member Services at 1-866-544-7504. They can confirm your status and provide a Maximum Out-of-Pocket letter upon request, which can be shown at your doctor's office to confirm that you no longer need to pay cost shares.

What counts toward my Maximum Out-of-Pocket limit?

• Medical Service Copays
• Medical Service Coinsurance
• Durable Medical Equipment (DME) Cost Shares

What does not count toward my Maximum Out-of-Pocket limit?

• Dental Service Cost Shares
• Hearing Aid Cost Shares
• Wellness Wallet & Eyewear Allowance
• Plan Premium
• Part D Prescription Drug Cost Shares

How can I request my Maximum Out-of-Pocket letter?

If you’ve met your Maximum Out-of-Pocket limit, call Member Services at 1-866-544-7504 to request your letter. If you haven’t met the limit, a letter will not be generated.

We connect you directly with trusted partners, making it easier than ever to manage your benefits. From exclusive discounts to personalized support, our vendors are here to help you get the most out of your membership. Direct access to the services and solutions you need. Explore what’s available and take control of your health and wellness today!

For detailed third-party vendor information, visit:

At Martin’s Point, we are committed to providing our members a fair and timely process for resolving any complaints or disputes. We encourage Martin’s Point Generations Advantage members to contact us with questions, concerns, or problems related to any benefits or service.

Please call us at 1-866-544-7504 (TTY: 711), 8am–8pm, seven days a week from October 1–March 31, and Monday through Friday the rest of the year, to discuss your concerns.

For detailed information, visit:

Better Access to Your Health Information

As part of the 21st Century Cures Act regulations, the Centers for Medicare and Medicaid (CMS) policy now requires that systems be put in place to make it easier for you to see your important health data. Under the systems, you’ll be able to:

• Easily access your health claims information, including treatment and prescription history and costs
• Find an up-to-date list of in-network providers
• Know which providers have agreed to provide electronic access to your health information

For detailed information, visit: