Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 3 of 8) in pdf

Enrollment Eligibility

Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period

between October 15 and December 7 of each year. Additionally, there are exceptions that may allow you to

enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period. Please read the below

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.

□ I am applying during the Annual Enrollment

□ I am leaving employer or union group

period (October 15 through December 7) for

coverage on

an effective date of January 1.

(insert date)

( __ __ /__ __ /__ __ __ __)

( M M / D D / Y

Y Y

I am new to Medicare.

□ 65

□ I recently involuntarily lost my creditable

Birthday

□ Disability Determination

prescription drug coverage (as good as

□ Existing Medicare (via disability) – Now turning

Medicare’s). I lost my drug coverage on

(insert date)

( __ __ /__ __ /__ __ __ __)

(insert date)

( __ __ /__ __ /__ __ __ __)

( M M / D D / Y

Y Y

( M M / D D / Y

Y Y

Change in Residence

□ I recently moved outside of the service area

Medicare Assistance Programs.

□ I have both Medicare and Medicaid or my state

for my current plan or I recently moved and

helps pay for Medicare premiums.

this plan is a new option for me.

□ I get extra help paying for Medicare prescription

□ I recently returned to the United States after

drug coverage.

living permanently outside of the U.S.

□ I belong to a pharmacy assistance program

(insert date)

( __ __ /__ __ /__ __ __ __)

provided by my state.

( M M / D D / Y

Y Y

□ I recently left a PACE program.

(insert date)

□ I am making this enrollment request

( __ __ /__ __ /__ __ __ __)

( M M / D D / Y

Y Y

between January 1 and February 14, and I

recently ended or plan on ending my

□ I no longer qualify for (government assisted)

enrollment in a Medicare Advantage plan.

extra help paying for my Medicare prescription

(insert date)

( __ __ /__ __ /__ __ __ __)

drug coverage. I stopped receiving extra help on

( M M / D D / Y

Y Y

(insert date)

( __ __ /__ __ /__ __ __ __)

□ My plan is ending its contract with

( M M / D D / Y

Y Y

Medicare, or Medicare is ending its contract

□ I live in or recently moved out of a Long-Term

with my plan.

Care Facility (for example, a nursing home). I

(insert date)

( __ __ /__ __ /__ __ __ __)

moved/will move into/out of the facility on

( M M / D D / Y

Y Y

(insert date)

( __ __ /__ __ /__ __ __ __)

( M M / D D / Y

Y Y

If none of these statements applies to you or you’re not sure, please contact us at 1-888-496-4174 to see if you

are eligible to enroll. We are open 24 hours a day, 7 days a week. TTY/TDD users call 711.

S2893_1634 Approved 06152016

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 3

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