Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 7 of 8) in pdf

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 7

Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield

Association.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield

of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a

joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for

Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue

MedicareRx (PDP) depends on contract renewal.

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield

Association.

Medicare Prescription Drug Plan Office & Producer Use Only:

Date Application Received by Agent/Broker/Rep:___________________________________________

Effective Date of Coverage: ________________________________

Enrollment Period Type: IEP: _______ AEP: ________ SEP: ______

Agent Individual Writing Code:__________________________________________

Agent/Broker/Rep Name:______________________________________________________________

Agent/Broker/Rep Signature: ___________________________________________

Agent/Broker/Reps Only – please fax the completed application to the following number within 24

hours of receipt: 1-401-459-5025

S2893_1634 Approved 06152016

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 7