Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 5 of 8) in pdf

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Paying Your Plan Premium

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Receive a bill

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Automatic Bank Draft Withdrawal from Checking or Savings Account

Please send us a VOIDED check and fill in the requested information, which allows us to deduct your

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monthly premium payment from your bank account.

Checking

Savings (check one)

By selecting Automatic Bank Withdrawal, I authorize the bank or financial organization named above

to pay my premium through electronic bank withdrawal payable to Blue MedicareRx. I authorize the

deduction of up to $300 at a time (only if the balance is such). The bank or other financial organization

will be fully protected in honoring these payments until notice from me canceling this request is received.

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Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check.

(Your monthly plan premium deduction may take up to 90 days to begin and will not cover any premiums for

which we have already sent you an invoice. Therefore, until your automatic deduction is approved, we will

continue to send you a paper bill each month. Please continue to pay your premium invoice for as long as

you receive it. In most cases, if Social Security/ Railroad Retirement Board accepts your request for automatic

deduction, the first deduction from your Social Security/Railroad Retirement Board benefit might not include all

premiums owed from your enrollment effective date up to the point withholding begins. If you owe any premiums

retroactive to the date of the Social Security/Railroad Retirement Board deductions, we will send you a paper bill

for those premiums. If Social Security/ Railroad Retirement Board does not approve your request for automatic

deductions, we will send you a paper bill for your monthly premiums.)

Note: the option to pay using a Credit Card will be included on your monthly invoice. You can also call us toll

free once your enrollment in the plan is active, at 1-888-496-4174, 24 hours a day, 7 days a week. TTY/TDD

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users call 711.

Please Read This Important Information

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription

drug coverage from your Medicare Advantage Plan that will meet your needs. By joining Blue MedicareRx, your

membership in your Medicare Advantage Plan may end. 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 currently have health coverage from an employer or union, joining Blue MedicareRx could affect

your employer or union health benefits. You could lose your employer or union health coverage if you join

Blue MedicareRx. Read the communications 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.

S2893_1634 Approved 06152016

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 5