BCBSMA PDP Sales Kit Book 11/01/2018 Approved by Jazmin 10/26/2018 1:44 PM

03

Disclosures



Blue MedicareRxSM (PDP) complies with applicable Federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, or sex. Blue MedicareRx does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex.

Blue MedicareRx:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other
formats)

• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages

If you need these services, call the number on the back of your Member ID Card. TTY/TDD users should call
711.

If you believe that Blue MedicareRx has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Blue MedicareRx (PDP)
Grievance Department Coordinator
P.O. Box 30016
Pittsburgh, PA 15222-0330

Phone: 1-866-884-9478
Fax: 1-866-217-3353

You can file a grievance in person, by mail, or fax. If you need help filing a grievance, Blue MedicareRx
Grievance Department is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ENGLISH KOREAN
ATTENTION: If you speak English, language 알림: 한국어를 하시는 경우 무료 통역 서비스가
assistance services, free of charge, are available to you. 준비되어 있습니다. 회원 카드 뒷면에 표시된
Call the number on the back of your Member ID Card. 전화번호(TTY: 711)로 연락주시기 바랍니다.
TTY: 711.

ARABIC M្របយOត័ N៖� -្KរបសHនិMេបEើអR�កន,យិ C‌AយMភាសBា㏸OែខD�រ IេសANវ‌ជនំ ួយែផ�កភាសា㏸េដ‌យមិនគិតឈល�
‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
‫ اﺗﺼﻞ ﺑﺎﻟﺮﻗﻢ اﻟﻤﺒﯿﻦ ﻋﻠﻰ ظﮭﺮ ﺑﻄﺎﻗﺔ اﻟﻌﻀﻮﯾﺔ‬.‫ﺗﺘﻮﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬

.711 :‫ ﻟﻠﺼﻢ واﻟﺒﻜﻢ‬.‫ اﻟﺨﺎﺻﺔ ﺑﻚ‬គឣឺ ‍ចរកបានសំរ‌បអ់ ក� ។

CHINESE ចរូ ទូរសព័ �េ�េលខេ�ខាងខង� ៃនបណ័ �សមា� លខ់ ន� សមាជកិ របសអ់ ក� ។ TTY:
小贴士：如果您说中文，欢迎使用免费语言协助服
务。请拨打您会员身份证上的电话号码。（TTY： 711។
711)。
POLISH
FRENCH UWAGA: Dla osób mówiących po polsku dostępna jest
ATTENTION : Si vous parlez français, des services bezpłatna pomoc językowa. Zadzwoń pod numer podany
gratuits d’interprétation sont à votre disposition. na odwrocie Twojej Członkowskiej karty ident. Tel. tekst.:
Veuillez appeler le numéro figurant au verso de votre 711.
Carte de membre. TTY: 711.
PORTUGUESE
FRENCH CREOLE ATENÇÃO: Se fala português, estão disponíveis serviços
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd gratuitos de assistência linguística na sua língua. Telefone
pou lang ki disponib gratis pou ou. Rele nimewo ki sou para o número no verso do seu Cartão de Identificação de
do Kat ID Manm ou an. TTY: 711. Membro. TTY: 711.

GREEK RUSSIAN
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, υπάρχει διαθέσιμη ВНИМАНИЕ: Если вы говорите на русском языке, вам
υπηρεσία γλωσσικής υποστήριξης, η οποία παρέχεται будут бесплатно предоставлены услуги переводчика.
δωρεάν. Καλέστε τον αριθμό στο πίσω μέρος της Звоните по телефону, указанному на обороте вашей
κάρτας μέλους (Αριθμός για άτομα με προβλήματα идентификационной карты участника. Телетайп: 711.
ακοής/ομιλίας: 711).
SPANISH
HINDI ATENCIÓN: Si usted habla español, tenemos servicios de
ध्यान द�िजए : अगर आप �हदं � बोलते ह� तो आपके �लए asistencia lingüística disponibles para usted sin costo
alguno. Llame al número que aparece al reverso de su
tarjeta de membresía. TTY: 711.

भाषा सहायता सवे ाएं मुफ्त उपलब्ध ह�। आपके सदस्य ID TAGALOG
काड्र के पीछे �दए गए नम्बर पर कॉल कर�। TTY: 711. Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyo
ng tulong sa wika, nang walang bayad, ay magagamit sa
ITALIAN iyo. Tawagan ang numero sa likod ng iyong ID card ng
ATTENZIONE: Se lei parla italiano, sono disponibili Miyembro. TTY: 711.
servizi gratuiti di assistenza linguistica nella sua lingua.
Chiami il numero che si trova sul retro della sua tessera VIETNAMESE
(Member ID Card). TTY: 711.
LƯU Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ
S2893_1709 hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Hãy gọi tới số
ở mặt sau Thẻ ID Thành Viên của quý vị. TTY: 711.

Important Notices

OUR COMMITMENT TO CONFIDENTIALITY (NOTICE
OF PRIVACY PRACTICES) AND WOMEN’S HEALTH
AND CANCER RIGHTS ACT (WHCRA) NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Commitment your information. We may use and disclose
information about you without your written
We respect your right to privacy. We will not authorization for the following purposes, to the
disclose personally identifiable information extent otherwise permitted or required by law:
about you without your permission, unless
the disclosure is necessary to provide our • You or Your Representatives—to you
services to you or is otherwise in accordance or your “personal representative” upon
with the law. request or to help you (or your personal
representative) understand treatment
Collection of Information options, benefits, or the rights available to
you. Your “personal representative” is a
We collect only the information about you person who has legal authority to make
that we need to operate our business. We health-related decisions on your behalf,
collect information from other parties, such such as a person with a health-care power
as your health care providers and employers. of attorney. Your request must be in writing.
Examples of the information we collect are (i) Please complete the Documentation of
medical and dental information from providers Legal Representative Status for Members
when they submit claims for services and (ii) form available on our website. You also
personal information such as name, address, may designate a family member or friend
and date of birth, which is most often to receive information and interact with us
supplied by you or your employer when you on your behalf. Your designation and any
enroll in a plan. subsequent revocation must be in writing.
Please complete the Member’s Designation
Use and Disclosure of Information of an Authorized Representative form on
our website. You may also call Member
We are required by law to protect the Service for a copy of these forms.
confidentiality of information about you and
to notify you in case of a breach affecting

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

• Treatment—to help health care providers • Research—for health-related research
manage or coordinate your health care studies that meet legal standards for
and related services. For example, we may protection of the individuals involved in
use and disclose information about you to the studies and their personal information.
inform providers of medications you take We may also create a database of our
or to remind you of appointments. members’ information that does not
include individual identifiers and use the
• Payment—to obtain payment for your database for research or other purposes,
coverage, pay claims for your health provided that the information cannot be
benefits, or help another health plan traced back to specific members.
or health care provider in its payment
activities. For example, we may use or • To Your Employer (or other plan sponsor),
disclose information about you to make if applicable, for administration of its
coverage determinations, administer health plan. This applies only if you receive
claims, or coordinate benefits with other coverage through an employer-sponsored
coverage you may have. plan (or plan sponsored by your union or
other entity). For example, we may disclose
• Health Care Operations—to perform other information about you to your employer (or
activities necessary for the operation of other plan sponsor) to confirm enrollment
our business, including customer service, in the plan or (if the employer or other
disease management, and determining how plan sponsor is self-insured) for claim
to improve the quality of care. For example, review and audits. We will disclose your
we may use or disclose information about information only to designated individuals.
you to respond to your call to customer That, along with legal prohibitions on
service, arrange for medical review of your use of your personal information for
claims, or conduct quality assessment and discriminatory purposes, helps protect
improvement activities. your information from unauthorized use.

• Legal Compliance—to comply with To carry out these purposes, we share
applicable law. For example, we may be information with entities that perform functions
required to use or disclose information for us subject to contracts that limit use and
about you to respond to regulatory disclosure for intended purposes. We use
authorities responsible for oversight of physical, electronic, and procedural safeguards
government benefit programs or our to protect your privacy. Even when allowed, we
business operations; to parties or courts limit uses and disclosures of your information to
in the course of judicial or administrative the minimum amount reasonably necessary for
proceedings; or pursuant to workers’ the intended task.
compensation laws.
The Health Insurance Portability and
• Government Agencies—under limited Accountability Act (HIPAA) generally does
circumstances established by law, to not override other laws that give people
public health authorities, coroners or greater privacy protections. As a result, we
medical examiners, law enforcement,
or other government officials

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

must comply with any state or federal privacy • You have the right to receive information
laws that require us to provide you with more about privacy protections. Your member-
privacy protections. For example, federal law education materials include a notice of
provides special protections for substance use your rights, and you may request a paper
disorder information; Massachusetts state law copy of this notice at any time.
restricts the disclosure of HIV and AIDS related
information. In addition, we will not use (and are • You have the right to inspect and get copies
prohibited from using) your genetic information of information that we use to make decisions
for underwriting purposes. about you. This is your designated record
set. Your request must be in writing. We may
Other Disclosures Require Your charge a reasonable fee for copying and
Written Authorization mailing you this information. Please complete
the Request for Access to Copies of Protected
Except as provided in this notice, we will not Health Information in Designated Record Set
use or disclose information about you without form to request copies of your information.
your written authorization. For example, we
must have your written authorization to use • You have the right to receive an accounting
or disclose your information for marketing of certain disclosures that we make of
purposes or (in most cases) to use or disclose information about you. Your request must
psychotherapy notes. Although we would need be in writing. Please complete the Members
written authorization to sell information about Request for an Accounting of Disclosures
you, we do not sell members’ information. form. Our response will exclude any
disclosures made in support of treatment,
You may revoke your authorization at any payment, and health care operations or that
time. Your authorization must be in writing. you authorized (among others). An example
Your revocation will not affect any action that of a disclosure that would be reported to
we have already taken in reliance on your you is our disclosure of your information in
authorization. If you would like us to disclose response to a court order.
information about you to a third party, please
complete the Permission for One-Time • You have the right to ask us to correct
Disclosure of Information form available on or amend information you believe to be
our website or call Member Service for a copy incorrect. Your request to correct or amend
of the form. information must be in writing. Please
complete the Members Request to Amend
Your Privacy Rights Protected Health Information form. If we
deny your request, you may ask us to make
You have the following rights with respect to your request part of your records.
information about you. You may exercise any
of these rights by calling the Member Service • You have the right to ask that we restrict or
number listed on your member ID card or refuse the disclosure of information about
contacting us at the address listed at the end you and that we direct communications to
of this notice. The forms listed below are also you by alternative means or to alternative
available on our website. locations. While we may not always be able to
agree to your request, we will make reasonable

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

efforts to accommodate requests. Unless to obtain the revised notice in our next regular
you’ve notified us to request a different mailing mailing to you. If you have any questions, please
address, Summary of Health Plan Payments call the Member Service number listed on your
statements for the subscriber, and all members member ID card, or write us at:
listed on the subscriber’s plan, are generally
delivered to the subscriber’s address. Under Blue Cross Blue Shield of Massachusetts
certain circumstances, you can request to not
receive statements for a particular service, Privacy Officer
or to have statements delivered through an
alternate method or to an alternate address, 101 Huntington Ave.
when required by state law. If you have
concerns about protecting the privacy of Suite 1300
your medical information in your statements,
you can have these statements delivered to Boston, MA 02199-7611
an address other than the plan subscriber’s
address, or have them delivered only via WHCRA NOTICE
electronic means. For help understanding your
delivery options, please call Member Service Did you know that your medical plan provides
at the number listed on your member ID card. benefits for many mastectomy-related services?
Your request and any subsequent revocation This is the case even if you were not covered
must be in writing. by Blue Cross Blue Shield of Massachusetts
at the time of the mastectomy. It’s required by
If you believe your privacy rights have been the Women’s Health and Cancer Rights Act of
violated, you have the right to complain to 1998. If you are covered for a mastectomy and
us using the grievance process outlined in elect breast reconstruction in connection with a
your benefit materials, or to the Secretary of mastectomy, then benefits are also provided for:
the U.S. Department of Health and Human
Services, without fear of retaliation. • All stages of reconstruction of the breast
on which the mastectomy has been
About This Notice performed;

The original effective date of this notice was April • Surgery and reconstruction of the
14, 2003. The effective date of the most recent other breast to produce a symmetrical
revision is indicated in the footer of this notice. appearance; and
We are required by law to provide you with this
notice of our legal duties and privacy practices • Prostheses and treatment of physical
and to abide by the notice for as long as it is in complications at all stages of the
effect. We reserve the right to change this notice. mastectomy, including lymphedemas.
Any changes will apply to all information that we
maintain, regardless of when it was created or Coverage will be provided as determined in
received. If we make a material change to this consultation with you and your attending doctor.
notice, we will post the revised notice on our The costs that you pay for these services are
website and notify you of the change and how the same as those you pay for other services
in the same category. To learn more, please
call the Member Service number on your
member ID card.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity.

ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you.
Call Member Service at the number on your ID card (TTY: 711).

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma.
Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de
idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross
and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO, Inc. © 2017 Blue
Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

175470M 32-7900 (10/17)



04

Enrollment



Blue MedicareRxSM (PDP)

Instructions on How to Fill Out the Blue MedicareRxSM (PDP) Enrollment Form

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

¨ 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

¨ 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 www.socialsecurity.gov/prescriptionhelp.

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

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

¨ 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 30001, Pittsburg, PA 15222-0330.

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.

ISf 2yo8u93n_e1e8d1a3n4a_pCpSoi2n8tm93e_n1t o8f1r3e4p_reCsentative (AOR) form, please note that it will be included in your new

enrollment kit.

S2893_18134_C

Blue MedicareRxSM (PDP) 2019

Blue MedicareRxSM (PDP) Medicare Prescription Drug Plan Individual Enrollment Form

Please contact Blue MedicareRx Value Plus (PDP) or Blue MedicareRx Premier (PDP)
if you need information in another format (Large Print).

To Enroll in Blue MedicareRx (PDP), Please Provide the Following Information:

Please check which plan you want to enroll in:

¨ Blue MedicareRx Value Plus $37.80 per month ¨ Blue MedicareRx Premier $127.90 per month

LAST Name: FIRST Name: Middle Initial ¨ Mr. ¨ Mrs. ¨ Ms.

Birth Date: Sex: Primary Phone Number: Alternate Phone Number:
() ()
( __ __ /__ __ /__ __ __ __) ¨M ¨F
(M M / D D / Y Y Y Y)

E-mail Address: [Optional] ___________________________________________________________________

Permanent Residence Street Address (P.O. Box is not allowed):

City: State: ZIP Code:

Mailing Address (only if different from Permanent Residence Address):

Street Address: City: State: ZIP
Code:

Emergency Contact: [Optional Field] ___________________________________________________________
Phone Number: [Optional] ___________________________________________________________________
Relationship to You [Optional]________________________________________________________________

Please Provide Your Medicare Insurance Information

Please take out your red, white, and blue Name (as it appears on your Medicare card):
Medicare card to complete this section.
_________________________________________
• Fill out this information as it appears Medicare Number
on your Medicare card

- OR - _______________________________

• Attach a copy of your Medicare card Is Entitled to: Effective Date
or your letter from Social Security or
the Railroad Retirement Board. HOSPITAL (Part A) __________________
MEDICAL (Part B) ___________________

You must have Medicare Part A or Part B (or both) to join
a Medicare prescription drug plan.

Enrollment Eligibility

Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period
between October 15 and December 7 of each year. Additionally, there are exceptions that may allow you to
enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period. Please read the below
statements carefully and check the box if the statement applies to you. By checking any of the following boxes
you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later
determine that this information is incorrect, you may be disenrolled.

□ I am applying during the Annual Enrollment □ I am leaving employer or union group
period (October 15 through December 7) for coverage on
an effective date of January 1.
(insert date) ( __ __ /__ __ /__ __ __ __)
I am new to Medicare.
□ 65th Birthday ( M M / D D / Y Y Y Y)
□ Disability Determination
□ Existing Medicare (via disability)–Now turning 65 □ I recently involuntarily lost my creditable
(insert date) ( __ __ /__ __ /__ __ __ __) prescription drug coverage (as good as
Medicare’s). I lost my drug coverage on
( M M / D D / Y Y Y Y)
(insert date) ( __ __ /__ __ /__ __ __ __)
Medicare Assistance Programs.
□ I recently had a change in my Medicaid (newly ( M M / D D / Y Y Y Y)

got Medicaid, had a change in level of Medicaid Change in Residence
assistance, or lost Medicaid) on (insert date) □ I recently moved outside of the service area

( __ __ /__ __ /__ __ __ __) for my current plan or I recently moved and
( M M / D D / Y Y Y Y) this plan is a new option for me.
□ I recently returned to the United States after
□ I recently had a change in my Extra Help paying living permanently outside of the U.S.
for Medicare prescription drug coverage (newly (insert date) ( __ __ /__ __ /__ __ __ __)
got Extra Help, had a change in the level of
Extra Help, or lost Extra Help) on (insert date) ( M M / D D / Y Y Y Y)

( __ __ /__ __ /__ __ __ __) □ I am enrolled in a Medicare Advantage plan
( M M / D D / Y Y Y Y) and want to make a change during the Medicare
Advantage Open Enrollment Period (MA OEP)
□ I have both Medicare and Medicaid (or my state between January 1 and March 31.
helps pay for my Medicare premiums) or I get (insert date) ( __ __ /__ __ /__ __ __ __)
Extra Help paying for my Medicare prescription
drug coverage, but I haven’t had a change. I am ( M M / D D / Y Y Y Y)
making this enrollment request between January
1 and September 30 and I understand I can only □ My plan is ending its contract with
make this request once per quarter. Medicare, or Medicare is ending its
contract with my plan.
□ I belong to a pharmacy assistance program
provided by my state. (insert date) ( __ __ /__ __ /__ __ __ __)

□ I recently left a PACE program. ( M M / D D / Y Y Y Y)
(insert date) ( __ __ /__ __ /__ __ __ __)
□ I was enrolled in a plan by Medicare (or my
( M M / D D / Y Y Y Y) state) and I want to choose a different plan. My
enrollment in that plan started on (insert date)
□ I live in or recently moved out of a Long-Term
Care Facility (for example, a nursing home). I (__ __ /__ __ /__ __ __ __)
moved/will move into/out of the facility on ( M M / D D / Y Y Y Y)

(insert date) ( __ __ /__ __ /__ __ __ __) □ I was affected by a weather-related
emergency or major disaster (as declared
( M M / D D / Y Y Y Y) by the Federal Emergency Management
Agency (FEMA). One of the other
statements here applied to me, but I was
unable to make my enrollment because of
the natural disaster.

□ Other Explain:_____________________

If none of these statements applies to you or you’re not sure, please contact us to see if you are eligible to enroll.

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-866-832-9702 (TTY: 711) 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

Please Answer the Following Questions:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal
employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to Blue MedicareRx? ¨ Yes ¨ No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage: ID # for this coverage: Group # for this coverage:

______________________________ ________________________ ________________________

______________________________ ________________________ ________________________

2. Are you a resident in a long-term care facility, such as a nursing home? ¨ Yes ¨ No

If “yes” please provide the following information:
Name of Institution: _______________________________
Address of Institution (number and street): _______________________________________________________
Phone Number of Institution: __________________________________________________________________

Please check the box below if you would prefer that we send you information in an accessible format:

¨ Large Print

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail
each month. You can also choose to pay your premium by automatic deduction from your Social Security
or Railroad Retirement Board benefit check each month.
If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the
Social Security Administration. You will be responsible for paying this extra amount in addition to your
plan premium. You will either have the amount withheld from your Social Security or Railroad Retirement
Board benefit check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to Blue
MedicareRx.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify,
Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment
penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra
Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call
1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of
your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare
doesn’t cover.

Please select a premium payment option. (If you don’t select an option, you will receive a monthly bill.)
Reminder, if you have secondary coverage that pays for part of your premiums (for example: from your
employer or an SPAP) then you must choose monthly bills that you can pay by mail in order for the secondary
coverage to be applied correctly.

¨ Receive a bill

¨ 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

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.

¨ Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check.
I get monthly beneifts from: ¨ Social Security ¨ RRB

(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.

Paying Your Plan Premium

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday 24 hours a day, 7 days a week
8:00 a.m. to 8:00 p.m.
8:00 a.m. to 8:00 p.m.,
4/1–9/30, Monday through Friday
8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

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.

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.

Signature: Today’s Date:

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.

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

ENRF-8580-19

Broker Box for Connecticut and Rhode Island Only:

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:
Connecticut: 1-866-342-7048
Rhode Island: 1-401-459-5025

187464 | 55-2043-19 (8/19)

Blue MedicareRxSM (PDP)

Instructions on How to Fill Out the Blue MedicareRxSM (PDP) Enrollment Form

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

¨ 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

¨ 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 www.socialsecurity.gov/prescriptionhelp.

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

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

¨ 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 30001, Pittsburg, PA 15222-0330.

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.

ISf 2yo8u93n_e1e8d1a3n4a_pCpSoi2n8tm93e_n1t o8f1r3e4p_reCsentative (AOR) form, please note that it will be included in your new

enrollment kit.

S2893_18134_C

Blue MedicareRxSM (PDP) 2019

Blue MedicareRxSM (PDP) Medicare Prescription Drug Plan Individual Enrollment Form

Please contact Blue MedicareRx Value Plus (PDP) or Blue MedicareRx Premier (PDP)
if you need information in another format (Large Print).

To Enroll in Blue MedicareRx (PDP), Please Provide the Following Information:

Please check which plan you want to enroll in:

¨ Blue MedicareRx Value Plus $37.80 per month ¨ Blue MedicareRx Premier $127.90 per month

LAST Name: FIRST Name: Middle Initial ¨ Mr. ¨ Mrs. ¨ Ms.

Birth Date: Sex: Primary Phone Number: Alternate Phone Number:
() ()
( __ __ /__ __ /__ __ __ __) ¨M ¨F
(M M / D D / Y Y Y Y)

E-mail Address: [Optional] ___________________________________________________________________

Permanent Residence Street Address (P.O. Box is not allowed):

City: State: ZIP Code:

Mailing Address (only if different from Permanent Residence Address):

Street Address: City: State: ZIP
Code:

Emergency Contact: [Optional Field] ___________________________________________________________
Phone Number: [Optional] ___________________________________________________________________
Relationship to You [Optional]________________________________________________________________

Please Provide Your Medicare Insurance Information

Please take out your red, white, and blue Name (as it appears on your Medicare card):
Medicare card to complete this section.
_________________________________________
• Fill out this information as it appears Medicare Number
on your Medicare card

- OR - _______________________________

• Attach a copy of your Medicare card Is Entitled to: Effective Date
or your letter from Social Security or
the Railroad Retirement Board. HOSPITAL (Part A) __________________
MEDICAL (Part B) ___________________

You must have Medicare Part A or Part B (or both) to join
a Medicare prescription drug plan.

Enrollment Eligibility

Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period
between October 15 and December 7 of each year. Additionally, there are exceptions that may allow you to
enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period. Please read the below
statements carefully and check the box if the statement applies to you. By checking any of the following boxes
you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later
determine that this information is incorrect, you may be disenrolled.

□ I am applying during the Annual Enrollment □ I am leaving employer or union group
period (October 15 through December 7) for coverage on
an effective date of January 1.
(insert date) ( __ __ /__ __ /__ __ __ __)
I am new to Medicare.
□ 65th Birthday ( M M / D D / Y Y Y Y)
□ Disability Determination
□ Existing Medicare (via disability)–Now turning 65 □ I recently involuntarily lost my creditable
(insert date) ( __ __ /__ __ /__ __ __ __) prescription drug coverage (as good as
Medicare’s). I lost my drug coverage on
( M M / D D / Y Y Y Y)
(insert date) ( __ __ /__ __ /__ __ __ __)
Medicare Assistance Programs.
□ I recently had a change in my Medicaid (newly ( M M / D D / Y Y Y Y)

got Medicaid, had a change in level of Medicaid Change in Residence
assistance, or lost Medicaid) on (insert date) □ I recently moved outside of the service area

( __ __ /__ __ /__ __ __ __) for my current plan or I recently moved and
( M M / D D / Y Y Y Y) this plan is a new option for me.
□ I recently returned to the United States after
□ I recently had a change in my Extra Help paying living permanently outside of the U.S.
for Medicare prescription drug coverage (newly (insert date) ( __ __ /__ __ /__ __ __ __)
got Extra Help, had a change in the level of
Extra Help, or lost Extra Help) on (insert date) ( M M / D D / Y Y Y Y)

( __ __ /__ __ /__ __ __ __) □ I am enrolled in a Medicare Advantage plan
( M M / D D / Y Y Y Y) and want to make a change during the Medicare
Advantage Open Enrollment Period (MA OEP)
□ I have both Medicare and Medicaid (or my state between January 1 and March 31.
helps pay for my Medicare premiums) or I get (insert date) ( __ __ /__ __ /__ __ __ __)
Extra Help paying for my Medicare prescription
drug coverage, but I haven’t had a change. I am ( M M / D D / Y Y Y Y)
making this enrollment request between January
1 and September 30 and I understand I can only □ My plan is ending its contract with
make this request once per quarter. Medicare, or Medicare is ending its
contract with my plan.
□ I belong to a pharmacy assistance program
provided by my state. (insert date) ( __ __ /__ __ /__ __ __ __)

□ I recently left a PACE program. ( M M / D D / Y Y Y Y)
(insert date) ( __ __ /__ __ /__ __ __ __)
□ I was enrolled in a plan by Medicare (or my
( M M / D D / Y Y Y Y) state) and I want to choose a different plan. My
enrollment in that plan started on (insert date)
□ I live in or recently moved out of a Long-Term
Care Facility (for example, a nursing home). I (__ __ /__ __ /__ __ __ __)
moved/will move into/out of the facility on ( M M / D D / Y Y Y Y)

(insert date) ( __ __ /__ __ /__ __ __ __) □ I was affected by a weather-related
emergency or major disaster (as declared
( M M / D D / Y Y Y Y) by the Federal Emergency Management
Agency (FEMA). One of the other
statements here applied to me, but I was
unable to make my enrollment because of
the natural disaster.

□ Other Explain:_____________________

If none of these statements applies to you or you’re not sure, please contact us to see if you are eligible to enroll.

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-866-832-9702 (TTY: 711) 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

Please Answer the Following Questions:

1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal
employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to Blue MedicareRx? ¨ Yes ¨ No

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage: ID # for this coverage: Group # for this coverage:

______________________________ ________________________ ________________________

______________________________ ________________________ ________________________

2. Are you a resident in a long-term care facility, such as a nursing home? ¨ Yes ¨ No

If “yes” please provide the following information:
Name of Institution: _______________________________
Address of Institution (number and street): _______________________________________________________
Phone Number of Institution: __________________________________________________________________

Please check the box below if you would prefer that we send you information in an accessible format:

¨ Large Print

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail
each month. You can also choose to pay your premium by automatic deduction from your Social Security
or Railroad Retirement Board benefit check each month.
If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the
Social Security Administration. You will be responsible for paying this extra amount in addition to your
plan premium. You will either have the amount withheld from your Social Security or Railroad Retirement
Board benefit check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to Blue
MedicareRx.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify,
Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment
penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra
Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call
1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of
your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare
doesn’t cover.

Please select a premium payment option. (If you don’t select an option, you will receive a monthly bill.)
Reminder, if you have secondary coverage that pays for part of your premiums (for example: from your
employer or an SPAP) then you must choose monthly bills that you can pay by mail in order for the secondary
coverage to be applied correctly.

¨ Receive a bill

¨ 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

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.

¨ Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check.
I get monthly beneifts from: ¨ Social Security ¨ RRB

(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.

Paying Your Plan Premium

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday 24 hours a day, 7 days a week
8:00 a.m. to 8:00 p.m.
8:00 a.m. to 8:00 p.m.,
4/1–9/30, Monday through Friday
8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

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.

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.

Signature: Today’s Date:

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.

Connecticut Residents: Massachusetts Residents: Rhode Island Residents: Vermont Residents:
1-888-496-4178 (TTY: 711)
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 1-800-505-2583 (TTY: 711) 24 hours a day, 7 days a week

24 hours a day, 7 days a week 10/1–3/31, 7 days a week, Monday through Friday

8:00 a.m. to 8:00 p.m., 8:00 a.m. to 8:00 p.m.

4/1–9/30, Monday through Friday

8:00 a.m. to 8:00 p.m.

Online: rxmedicareplans.com

ENRF-8580-19

Broker Box for Connecticut and Rhode Island Only:

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:
Connecticut: 1-866-342-7048
Rhode Island: 1-401-459-5025

187464 | 55-2043-19 (8/19)



For More Information, or to Enroll:

Call: 1-800-678-2265 (TTY: 711)
October 1 – March 31, 8:00 a.m. - 8:00 p.m. ET
Seven days a week

April 1 – September 30, 8:00 a.m. - 8:00 p.m. ET
Monday through Friday

or
Visit: www.bluecrossma.com/medicare

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue
Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

188828 (11/(1001//1188))