Medicare Prescription Drug Plan Individual Enrollment Form Page 4
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8Please answer the following questions:
1. Are you an existing Blue Cross and Blue Shield of Texas Medicare member who is changing plans?
Yes
No
2. Some individuals may have other drug coverage, including other private insurance, TRICARE, federal employee
health benefits coverage, VA benefits, or state pharmaceutical assistance programs.
Do you have existing prescription drug coverage?
Yes
No
Name of existing coverage: ____________________________________________________________________
Will you have other prescription drug coverage in addition to Blue Cross MedicareRx?
Yes
No
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:
____________________________
_________________________
_________________________
3. 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
Braille/Large Print
Please contact Blue Cross MedicareRx at 1-866-288-3549 if you need information in another format or language
than what is listed above. TTY/TDD users should call 711. Our office hours are 8 a.m. – 8 p.m., local time,
7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example,
voicemail) will be used on weekends and holidays.
Please Read this Important Information
STOP
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 Blue Cross MedicareRx, 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 Blue Cross MedicareRx could
affect your employer or union health benefits. You could lose your employer or union health coverage if you
join Blue Cross MedicareRx. 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.
Applicant LAST name:
FIRST name:
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Parent category: Medical