Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 4 of 8) in pdf

Please Answer the Following Questions:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal

employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.



Will you have other prescription drug coverage in addition to Blue MedicareRx?

Yes

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage:

ID # for this coverage:

Group # for this coverage:

______________________________

________________________

______________________________

________________________



2. Are you a resident in a long-term care facility, such as a nursing home?

Yes

If “yes” please provide the following information:

Name of Institution: _______________________________

Address of Institution (number and street):________________________________________________________

Phone Number of Institution:___________________________________________________________________

Please check the box below if you would prefer that we send you information in another format:



Large Print

Please contact Blue MedicareRx at 1-888-496-4174 if you need information in a format other than what is listed

above. TTY/TDD users should call 711. Our office hours are 24 hours a day, 7 days a week.

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail

each month. You can also choose to pay your premium by automatic deduction from your Social Security

or Railroad Retirement Board benefit check each month. If you are assessed a Part D-Income Related

Monthly Adjustment Amount, you will be notified by the Social Security Administration. 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 Railroad Retirement Board benefit check or be billed

directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to Blue MedicareRx.

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

Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual

deductibles, and co-insurance. Additionally, 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 about this extra

help, 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

If you qualify for extra help with your Medicare prescription drug coverage costs, 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.

Please select a premium payment option. (If you don’t select an option, you will receive a monthly bill.)

Reminder, if you have secondary coverage that pays for part of your premiums (for example: from your

employer or an SPAP) then you must choose monthly bills that you can pay by mail in order for the secondary

coverage to be applied correctly.

S2893_1634 Approved 06152016

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 4

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