Member Resources for 2025

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)

H5591-015-001 - Lincoln, Oxford, Piscataquis, Somerset, Waldo Counties in Maine. For Belknap, Carroll, Coos and Grafton Counties in New Hampshire (PDF)

H5591-015-002 - Aroostook, Franklin, Hancock, Knox, Penobscot and Washington Counties in Maine (PDF)

H5591-005 - Cheshire, Hillsborough, Merrimack, Rockingham, Strafford and Sullivan Counties in New Hampshire (PDF)

H5591-006-001 - Cumberland and York County in Maine (PDF)

H5591-006-002 - Androscoggin, Kennebec and Sagadahoc Counties in Maine (PDF)

Alliance (HMO)

H5591-003 - All Maine Counties and All New Hampshire Counties (PDF)

Value Plus (HMO-POS)

H5591-009 - All Maine Counties (PDF)

Select (LPPO)

H1365-001 - Androscoggin, Aroostook, Cumberland, Franklin, Hancock, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, Washington and York Counties in Maine, and Cheshire, Coos, Hillsborough, Merrimack, Rockingham, Strafford and Sullivan Counties in New Hampshire (PDF)

Access (LPPO)

H1365-004-002 - Belknap, Carroll, Coos, and Grafton Counties in New Hampshire (PDF)

H1365-004-003 - Cheshire, Hillsborough, Merrimack, Rockingham, Strafford and Sullivan Counties in New Hampshire (PDF)

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

Summary of Benefits Prime (HMO-POS), Select (LPPO), Access (LPPO), Value Plus (HMO), and Alliance (HMO) (PDF)

Wellness Wallet Reimbursement Request

ONLINE REIMBURSEMENT REQUEST: Try this new option for easier submission and quicker processing!

Submit your Wellness Wallet reimbursement request online:

REQUEST BY MAIL: Use this form for items/services covered under your 2025 Wellness Wallet reimbursement benefit up to your plan’s annual limit. 

2025 Member Reimbursement Form Wellness Wallet/Eyewear (PDF)

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. 

Learn more about this benefit on our Wellness Wallet Benefit page.

Eyewear Reimbursement Request

ONLINE REIMBURSEMENT REQUEST: Try this new option for easier submission and quicker processing!

Submit your Prescription Eyewear reimbursement request online:

REQUEST BY MAIL: Use this form for reimbursement for items eligible under your prescription eyewear benefit up to your plan's annual limit. (DO NOT use this form if your eyewear purchase is due to recent cataract surgery. In this case, use the Medical Services Reimbursement Form seen below.)

2025 Member Reimbursement Form Wellness Wallet/Eyewear (PDF)

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.

Learn more about this benefit on our Vision Benefits page.

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)

Learn more about this benefit on our Contact and Eyeglasses After Cataract Surgery page.

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) 

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

Authorization to Release Information (PDF)
Use this form to authorize a designated representative to discuss certain aspects of your health 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.

Medicare Appointment of Representative (PDF)
Use this form to appoint a representative who can assist with all Medicare-related inquiries.

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.

Part D Senior Savings Model Eligible Insulin Drugs (PDF)
This is a list of the Part D Senior Savings Model for eligible insulin drugs.

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.

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.

Stay connected and secure with LifeStation

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 or looking to take advantage of our value-added discount, LifeStation ensures you're always connected when it matters most.

COVERED MEDICAL BENEFIT (ALLIANCE MEMBERS ONLY)

For eligible Martin's Point Generations Advantage Alliance 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. Covered devices include:

• In-home landline systems
• In-home cellular systems
• Mobile units with GPS and WiFi
• Optional fall detection

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

How to Access 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.

Devices & Pricing:

• In-Home Landline: $13.95/month
• In-Home Cellular: $13.95/month
• In-Home Cellular with Fall Detection: $18.95/month
• Mobile Unit with GPS/WiFi: $13.95/month
• Mobile Unit with GPS/WiFi & Fall Detection: $18.95/month

GENERATIONS ADVANTAGE DISCOUNT ON MEDICAL ALERT DEVICES

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

How to Access 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 Mobile: $25.95/month
• Mobile with GPS: $29.95/month
• Fall Detection (optional add-on): $5.00/month

MANAGING YOUR LIFESTATION SERVICE

Once enrolled in either option, LifeStation makes it easy to manage your service and get support when you need it:

• Customer Service Number: 1-800-998-2400 for troubleshooting or to explore device add-ons.

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 our 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.

As a Martin’s Point Generations Advantage member, you are eligible to receive FREE, personalized care management. Sign up for a dedicated medical or behavioral health care manager who will help you succeed at leading a healthy, active, and full life.

Our care managers can help you:

• Manage your health care

• Navigate your health plan

• Understand medications

• Find community support and resources

We want to help you live the healthiest life possible. Get started by calling a Martin’s Point care manager at 1-877-659-2403 or visit our Health Services page for more details.

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.

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.

Eligibilitly: 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.

Benefit Details:

• 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

Pay your Generations Advantage plan premium online.

Empower Your Health Care Decisions

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. Visit the Clinical Coverage Criteria page for more information.

Understanding Your 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.

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.

Talk with a trained nurse anytime, 24 hours a day, 7 days a week, to answer any questions about symptoms, injuries, or illness. 

Call 1-800-530-1021 if you need to know:

• If a cut requires stitches

• If you should head to an urgent care clinic, the ER, or wait until morning to see your doctor

• General information about a condition, medication, or other health concerns

This service is provided by Carenet Healthcare Services in partnership with Martin's Point. This service is not intended to take the place of your primary care provider.

Important Information for Members Traveling Abroad

When traveling outside the United States, it's crucial to understand how your health care coverage works and the requirements of your destination country.

Generations Advantage plans reimburse for urgent and emergency care services received out of the country, applying the in-network copays and coinsurance specific to your plan. However, please note that coverage does not guarantee your eligibility to receive care or medications in countries other than the US. Eligibility for medical services and medications is determined by each country and can vary widely.

We strongly recommend that members traveling abroad seek information regarding health care policies and procedures from each destination country prior to departure. This can help you avoid any issues and ensure you are prepared in case of a medical emergency.

For further assistance, please contact our Member Services team before your trip.

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