Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 6 of 8) in pdf

Please Read and Sign Below:

By completing this enrollment application, I agree to the following:

Blue MedicareRx is a Medicare drug plan and has a contract with the Federal government. I understand that this

prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my

Medicare Part A or Part B coverage. It is my responsibility to inform Blue MedicareRx of any prescription drug

coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time – if I

am currently in a Medicare Prescription Drug Plan, my enrollment in Blue MedicareRx will end that enrollment.

Enrollment in this plan is generally for the entire year. Once I enroll, I understand that I may only leave this plan

or make changes during the Annual Enrollment Period (October 15 – December 7 each year), unless I qualify for

a special enrollment period sooner under certain special circumstances allowed by CMS.

Blue MedicareRx serves a specific service area. If I move out of the area that Blue MedicareRx serves, I need to

notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network

pharmacies except in an emergency when I cannot reasonably use Blue MedicareRx network pharmacies. Once

I am a member of Blue MedicareRx, I have the right to appeal plan decisions about payment or services if I

disagree. I will read the Evidence of Coverage document from Blue MedicareRx when I get it to know which rules

I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable

prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my

premium for Medicare prescription drug coverage in the future.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or

contracted with Blue MedicareRx, he/she may be paid based on my enrollment in Blue MedicareRx.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance

or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid

program and the Medicare Savings Program.

Release of Information:

By joining this Medicare prescription drug plan, I acknowledge that Blue MedicareRx will release my information

to Medicare and other plans as is necessary for treatment, payment and health care operations. I also

acknowledge that Blue MedicareRx will release my information, including my prescription drug event data, to

Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and

regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I

intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under State law

where I live) on this application means that I have read and understand the contents of this application. If signed

by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under

State law to complete this enrollment and 2) documentation of this authority is available upon request by

Medicare.

Today’s Date:

Signature:

If you are the authorized representative, you must sign above and provide the following information:

Name: ____________________________________________________

Address: __________________________________________________

__________________________________________________________

Phone Number: (_____) ______________________________________

Relationship to Enrollee ______________________________________

Note : 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 Page 6

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