Medicare Prescription Drug Plan Individual Enrollment Form Page 5
Download a blank fillable Medicare Prescription Drug Plan Individual Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medicare Prescription Drug Plan Individual Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8Please Read and Sign Below:
By completing this enrollment application, I agree to the following:
Blue Cross MedicareRx 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 Blue Cross MedicareRx 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 Blue Cross MedicareRx 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.
Blue Cross MedicareRx serves a specific service area. If I move out of the area that Blue Cross MedicareRx
serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must
use network pharmacies except in an emergency when I cannot reasonably use Blue Cross MedicareRx network
pharmacies. Once I am a member of Blue Cross MedicareRx, I have the right to appeal plan decisions about
payment or services if I disagree. I will read the Evidence of Coverage document from Blue Cross MedicareRx
when I get it to know which rules I must follow to get coverage.
I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable
prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my
premium for Medicare prescription drug coverage in the future.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or
contracted with Blue Cross MedicareRx, he/she may be paid based on my enrollment in Blue Cross MedicareRx.
Counseling services may be available in my state to provide advice concerning Medicare supplement insurance
or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid
program, and the Medicare Savings Program.
Subscriber hereby expressly acknowledges its understanding this agreement constitutes a contract solely
between Subscriber and Blue Cross and Blue Shield of Texas (BCBSTX), which is an independent corporation
operating under a license from the Blue Cross and Blue Shield Association, an Association of Independent
Blue Cross and Blue Shield Plans (the “Association”), permitting BCBSTX to use the Blue Cross and/or Blue
Shield Service Marks in the State of Texas, and that BCBSTX is not contracting as the agent of the Association.
Subscriber further acknowledges and agrees that it has not entered into this agreement based upon
representations by any person other than BCBSTX and that no person, entity, or organization other than BCBSTX
shall be held accountable or liable to Subscriber for any of BCBSTX’s obligations to Subscriber created under this
agreement. This paragraph shall not create any additional obligations whatsoever on the part of BCBSTX other
than those obligations created under other provisions of this agreement.
Release of Information:
By joining this Medicare prescription drug plan, I acknowledge that Blue Cross MedicareRx will release my
information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also
acknowledge that Blue Cross MedicareRx will release my information, including my prescription drug event data,
to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and
regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I
intentionally provide false information on this form, I will be disenrolled from the plan.
I understand that my signature (or the signature of the person authorized to act on my behalf under state law
where I live) on this application means that I have read and understand the contents of this application. If signed
by an authorized individual (as described below), this signature certifies that: 1) this person is authorized under
state law to complete this enrollment and 2) documentation of this authority is available upon request
by Medicare.
Applicant LAST name:
FIRST name:
5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ssa-1026b-ocr-sm-inst - Statement Foe Continuing Eligibility For Extra Help With Medicare Prescription Drug Plan Costs
Legal
Form Ssa-1020-inst - General Instructions For Completing The Application For Extra Help With Medicare Prescription Drug Plan Costs
Legal
Form Ssa-1021-inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs
Legal
Related Categories
Parent category: Medical