Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form printable pdf download

Instructions on How to Fill Out the Blue MedicareRx

(PDP) Enrollment Form

NOTE: If you would like to save time and enroll online in one of our Blue MedicareRx plans, please go to

, select your state and then click on the “Enroll” tab to complete our secure online

enrollment form.

Please review all plan information carefully before making your selection. Once you have selected a plan, make

sure you use this checklist to ensure you have filled out the application completely:



IMPORTANT: Check which plan you want to enroll in. This is required for your application to be

considered complete.



Fill out the form completely, including your personal information and permanent residence street address

(and mailing address only if different from your permanent residence street address).



Write in your Medicare information or enclose a copy of your Medicare card or a copy of the verification

letter of your Medicare entitlement from Social Security or the Railroad Retirement Board.



IMPORTANT: Review the section on the Enrollment Eligibility carefully and choose the scenario that best

describes your eligibility status. This response is necessary and will determine your eligibility to enroll in

the plan.



Fill out the section on other drug coverage, as enrollment in a Blue MedicareRx plan may affect the drug

coverage you currently have.



Fill out the section on being a resident of a long-term care facility such as a nursing home, and include

the institution’s name, address and phone number.



You can find out if you are eligible for extra help to pay for your prescription drug costs by contacting

your local Social Security office, or by calling Social Security at 1-800-772-1213 (TTY users should call

1-800-325-0778), or by applying online at



Read the Important Information and Agreement sections. If you have any questions, call Blue

MedicareRx at 1-888-496-4174 (TTY/TDD: 711), 24 hours a day, 7 days a week.



Sign and date the enrollment form before returning it to us. Any enrollment forms received unsigned

cannot be processed and may result in delayed enrollment.



Once you have completed filling out the Enrollment Form, please return it to us in the business reply

envelope provided; or mail it directly to Blue MedicareRx P.O. BOX 52067, Phoenix, AZ 85072-9854

If you are filling out the enrollment form for someone else: Please be sure to sign the enrollment form and

note your contact information and relationship to the enrollee. If you are authorized to act on behalf of

the enrollee under the laws of the state where the enrollee resides, your signature certifies that:



You are authorized under State law to complete this enrollment, and



Documentation of this authority is available upon request.

If you need an appointment of representative (AOR) form, please note that it will be included in your new

enrollment kit.

S2893_1634 Approved 06152016

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

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