Medicare Prescription Drug Plan Individual Enrollment Form (Page 3 of 4) in pdf

Please Answer the Following Questions:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal

employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

□Yes □ No

Will you have other prescription drug coverage in addition to EnvisionRx Plus Clear Choice?

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage:

ID # for this coverage:

Group # for this coverage:

_____________________________________________

______________________

_________________________

2. Are you a resident in a long-term care facility, such as a nursing home? □Yes □ No

If “yes” please provide the following information:

Name of Institution: _________________________________________________

Address & Phone Number of Institution (number and street):_______________________________________________

Please check one of the boxes below if you would prefer that we send you information in a language other

than English or in another format:

______ Spanish (Español)

______ Large Print

________ Audio Format

Please contact EnvisionRx Plus Clear Choice at 1-866-250-2005 if you need information in another format or

language than what is listed above. TTY users should call 711. Our office hours are 24 hours a day, 7 days a

week.

Please Read This Important Information

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription

drug coverage from your Medicare Advantage Plan that will meet your needs. By joining EnvisionRx Plus Clear

Choice, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and

hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage

Plan sends you and if you have questions, contact your Medicare Advantage Plan.

If you currently have health coverage from an employer or union, joining EnvisionRx Plus Clear Choice

could affect your employer or union health benefits. You could lose your employer or union health coverage if

you join EnvisionRx Plus Clear Choice. Read the communications your employer or union sends you. If you have

questions, visit their website, or contact the office listed in their communications. If there isn’t information on

whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below:

By completing this enrollment application, I agree to the following:

EnvisionRx Plus Clear Choice is a Medicare drug plan and has a contract with the Federal government. I

understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need

to keep my Medicare Part A or Part B coverage. It is my responsibility to inform EnvisionRx Plus Clear Choice

of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription

drug plan at a time – if I am currently in a Medicare Prescription Drug Plan, my enrollment in EnvisionRx Plus

Clear Choice will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may

leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment

Period (October 15 – December 7), unless I qualify for certain special circumstances.

S7694_2015 E1 App_CC2 Approved 01212015

Page 3 of 4

Medicare Prescription Drug Plan Individual Enrollment Form Page 3

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