Medicare Prescription Drug Plan Individual Enrollment Form
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8Blue Cross MedicareRx
Medicare Prescription Drug Plan Individual Enrollment Form
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Please contact Blue Cross MedicareRx if you need information in another language or format (Braille).
To enroll in Blue Cross MedicareRx, please provide the following information:
Please check the plan you want to enroll in:
Blue Cross MedicareRx Basic (PDP)
Blue Cross MedicareRx Value (PDP)
Blue Cross MedicareRx Plus (PDP)
SM
SM
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$29.60 per month
$63.20 per month
$163.00 per month
LAST name:
FIRST name:
Middle Initial:
Mr.
Mrs.
Ms.
Birth Date:
Sex:
Home Phone Number:
M
F
( M M / D D / Y Y Y Y )
Permanent Residence Street Address (P .O. Box is not allowed):
City:
State:
ZIP Code:
Mailing Address (only if different from your Permanent Residence Address):
Street Address:
City:
State:
ZIP Code:
Emergency Contact:
Phone Number:
Relationship to You:
Email Address:
Please Provide Your Medicare Insurance Information
Please take out your Medicare card
to complete this section.
• Please fill in these blanks so they match your
SAMPLE ONLY
Name:
red, white and blue Medicare card.
– OR –
Medicare Claim Number
Sex
• Attach a copy of your Medicare card or your
— — — - — — - — — — —
letter from Social Security or the Railroad
Retirement Board.
is Entitled To
Effective Date
HOSPITAL (Part A)
You must have Medicare Part A or Part B (or both)
to join a Medicare prescription drug plan.
MEDICAL (Part B)
Applicant LAST name:
FIRST name:
1
Y0096_ENR_TX_PDENRFRM16 Approved 10012015
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Parent category: Medical