Fillable Medicareblue Rx Individual Change Form (Page 3 of 6) in pdf

Enrollee name:

q Other Special Enrollment Period not identified above

If none of the statements apply to you or if you are not sure, please contact MedicareBlue Rx Customer

Service (the phone numbers are on the front of this form) to see if you are eligible to enroll.

If you have special needs, alternative formats are available. Please contact MedicareBlue Rx Customer

Service at the phone numbers on the front of this form.

D. PAYING YOUR PLAN PREMIUM:

You can continue your current premium payment method for next year or change it. Please select a

premium payment option:

q Keep my current premium payment option

q Receive a paper bill. Do not send a premium payment with this application.

q Social Security deduction

q Railroad Retirement Board deduction

You can choose to pay your monthly plan premium, including any late enrollment penalty, each month by

mail or by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit

check. You may also choose automatic deduction from your Social Security or RRB checks after you are

enrolled. If Social Security/RRB does not approve your automatic deduction request, we will send you

paper bills for your monthly premiums and resubmit your request. Once approved, it can take two or more

months for the deduction to begin. During this time, you will receive paper bills and be responsible for

paying your premium directly to the plan until the deduction begins. If you do not pay your premium for

the months before the deduction takes effect, you may be disenrolled from the plan. Neither Social

Security nor RRB allow retroactive withholding requests.

If you are assessed a Part D-Income Related Monthly Adjustment Amount (IRMAA), the Social Security

Administration will notify you. You will be responsible for paying this extra amount in addition to your

plan premium. You will either have the amount withheld from your Social Security or RRB check or be

billed directly by Medicare. Do NOT pay MedicareBlue Rx the Part D-IRMAA.

You can also choose to pay by Electronic Funds Transfer (EFT). You must sign and date the form, and send it

along with a voided check to the plan. Contact Customer Service for a form at the phone number on the

front of this form. It may take up to two months to process your request. Please pay your premiums billed

to you on paper until your EFT is active. Any unpaid premiums due when EFT takes effect will be deducted

at that time to bring your account up-to-date.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you

qualify, Medicare could pay for 75 percent or more of your drug costs including monthly prescription drug

premiums, annual deductibles and coinsurance. Those who qualify won’t have a coverage gap or a late

enrollment penalty. Many people are eligible for these savings and don’t even know it. For more

information, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users

should call 1-800-325-0778. You can also apply for extra help online at

prescriptionhelp. If you qualify for extra help, Medicare will pay all or part of your plan premium. If

Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will receive a bill each month.

Medicareblue Rx Individual Change Form Page 3