Enrollment Request Form - United Healthcare - 2018
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Employer Group Name:
Baltimore County
Group Number/GPS ID:
024896
2018 Enrollment Request Form
GPS Branch Number:
Effective Date:
001
Please contact the plan if you need this information in another language or format (Braille).
Please check the plan you want:
o AARP MedicareRx Walgreens (PDP) W
Please Read This Important Information
This is a Part D plan. It’s designed to help pay the cost of prescription drugs. Note: If you have a
Medicare Advantage plan:
· You may already have drug coverage
· You will lose that plan automatically when you sign up for a Part D plan. This means you
would lose your medical coverage. This will affect both your doctor and hospital coverage
as well as your prescription drug coverage. Read the information that your Medicare
Advantage plan sends you and if you have questions, contact your Medicare Advantage
plan. If you have an MA-only PFFS plan, you may still enroll in a PDP and will not lose your
MA-only PFFS plan.
If you currently have health coverage from an employer or union, joining this plan could affect
your employer or union health benefits. You could lose your employer or union coverage if you
join this plan. Read the communication your employer or union sends you. If you have
questions, visit their website, or contact the office listed in their communications. If there isn’t
information on whom to contact, your benefits administrator or the office that answers
questions about your coverage can help.
Information about you.
Please type or print in black or blue ink.
o Mr.
Last Name
First Name
Middle Initial
o Mrs.
o Ms.
Birth Date
MM/DD/YYYY
Gender ¨ Male ¨ Female
Main Phone Number (
)
Other Phone Number (
)
—
—
Enrollee Name
Agent Name / ID No.
Y0066_PDP05232017_001 Approved
PDEX18PD4114292_000
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