Medicareblue Rx Individual Change Form Page 2
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6Please mail this form to:
MedicareBlue Rx
MEDICAREBLUE RX
P.O. Box 3178
INDIVIDUAL CHANGE FORM
Scranton, PA 18505
A. MEMBER INFORMATION (please print clearly):
Last Name:
First Name:
Middle Initial:
Member Number (Printed on your MedicareBlue Rx
Medicare Claim Number (Printed on your red, white
ID card):
and blue Medicare ID card):
Home Phone Number:
Alternate Phone Number (optional): E-mail Address (optional):
Permanent Residence Street Address (P.O. Box is not allowed):
City:
State:
ZIP Code:
B. PLAN OPTIONS (for premium information, see your Summary of Benefits):
Please check the box below for the plan option you wish to change to:
MedicareBlue Rx:
q Standard
q Premier
C. ENROLLMENT PERIOD DETERMINATION:
Typically, you may only enroll or change plan options in a Medicare Prescription Drug Plan
during the annual enrollment period between October 15 and December 7. Additionally, there are
exceptions that may allow you to change your plan option in a Medicare Prescription Drug Plan outside
of the annual enrollment period. Please read the following statements carefully and check the box if the
statement applies to you. By checking any of the following boxes you are certifying that, to the best of
your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is
incorrect, you may be disenrolled. Your effective date will generally be the first of the month after your
form is received by the plan.
q I am enrolling during the annual enrollment period, October 15 to December 7, for an effective date
on the following January 1. (Note: The enrollment application must be received by December 7 for
the enrollment to be effective on the following January 1.)
q I have both Medicare and Medicaid, or my state helps pay for my Medicare premiums.
q I get extra help paying for Medicare prescription drug coverage as of (mm/dd/yyyy)
.
q I no longer qualify for extra help paying for my Medicare prescription drug coverage. I received notice
of loss of extra help on (mm/dd/yyyy)
.
q I am moving into or live in a Long-Term Care Facility (for example, a nursing home or long-term care
facility). I moved or will move into the facility on (mm/dd/yyyy)
.
q I am moving out of a Long-Term Care Facility (for example, a nursing home or long-term care facility)
on (mm/dd/yyyy)
.
q I belong to Big Sky Rx (a state pharmaceutical assistance program) provided by the state of Montana.
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