Medicareblue Rx Individual Change Form
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6Individual Change Form
Dear Member:
Complete this form only if you wish to change your MedicareBlue Rx (PDP)
plan option. For premium or other changes, please call Customer Service (see phone
numbers below).
To change to a different Medicare Prescription Drug Plan option with MedicareBlue Rx,
fill out this form by checking the plan option you want and signing the form. Then
mail the completed form back to us.
You may change your plan option during the annual enrollment period, from
October 15 to December 7. Generally, you may not make changes at other times unless
you meet certain special exceptions (see the Enrollment Period Determination section).
For more information about enrollment periods please call Customer Service.
If you qualify for extra help with your prescription drug costs you may enroll in, or
disenroll from, a plan at any time. If you lose this extra help during the year, your
opportunity to make a change continues for two months after you are notified that
you no longer qualify for extra help.
If you select another plan option and we receive your completed form by the end of
any month, your new benefit plan will generally begin the first of the following month.
Selections made during the annual enrollment period (October 15-December 7) are
effective January 1.
If you have any questions, please call MedicareBlue Rx Customer Service at
1-888-832-0075, 8 a.m. to 8 p.m., daily, Central and Mountain Times. TTY hearing
impaired users call 711.
Thank you.
S5743_072213_B03_RE CMS Approved 08/19/2013
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