BCBSMA PDP Sales Kit Book June 2022 Approved By Danielle Roy 5/19/2022 12:22 PM

03

Disclosures



NONDISCRIMINATION NOTICE

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. It does not exclude people or treat them differently
because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

Blue Cross Blue Shield of Massachusetts provides:

• Free aids and services to people with disabilities to communicate effectively
with us, such as qualified sign language interpreters and written information
in other formats (large print or other formats).

• Free language services to people whose primary language is not English,
such as qualified interpreters and information written in other languages.

If you need these services, call Member Service at the number on your ID card.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these
services or discriminated in another way on the basis of race, color, national origin, age,
disability, sex, sexual orientation, or gender identity, you can file a grievance with the
Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of
Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689
(TTY: 711); fax at 1-617-246-3616; or email at [email protected].

If you need help filing a grievance, the Civil Rights Coordinator 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 online at ocrportal.hhs.gov; by mail at U.S. Department
of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building
Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD/TTY).

Complaint forms are available at hhs.gov.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee
of the Blue Cross and Blue Shield Association.
000893478 55-2067 (9/21)



Translation Resources

Proficiency of Language ATsRsAisNtSaLnAcTeIOSNeRrvEiScOeUsRCES

Proficiency of Language Assistance Services

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).
Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的
号码联系会员服务部（TTY 号码：711）。
Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang
disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou
Malantandan TTY: 711).
Vietnamese/Tiếng Việt: LƯUÝ: Nếu quý vị nóiTiếngViệt,các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho
quý vị miễnphí.Gọi cho Dịch vụ Hội viêntheosố trên thẻ ID của quý vị (TTY: 711).
Russian/Русский: ВНИМАНИЕ:если Выговорите по-русски,Выможете воспользоваться бесплатными
услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанномув Вашей
идентификационнойкарте (телетайп:711).
Arabic/‫ةيبر‬:

‫ اتصل بخدمات الأعضاء على الرقم الموجود على بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬

Mon-Khmer, Cambodian/ខ្រែម : ការជូនដំណឹ ង៖ ប្រសិនប្រើអនក្ និយាយភាសា ខ្មែរ
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អន្ក។ សូមទូរស័ព្ទបៅខ្ន្កបសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណណ្ សរាគា េ់្ួលៃនរ្រស់អ្នក (TTY: 711)។
French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont
disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré
(TTY : 711).
Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza
linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa
(TTY: 711).
Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있
습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.

Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Εάν µιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής
βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθµό της κάρτας
µέλους σας (ID Card) (TTY: 711).

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

Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy
językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze
(TTY: 711).

Hindi/हिदं ी: ध्यान दंे: ्दद आप दिनददी बोलते िंै, तो भयाषया सिया्तया सेवयाएँ, आप कके रलंे ल(टएदी.टनदीन.व:शयाईलु .:क711).
उपलब्ध िंै। सदस् सेवयाओं को आपके आई.डी. कयाडड् पर ददए गए नबं र पर कॉल

Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગજુ રયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડડ્ પર આપલે યા નંબર પર Member Service ને કૉલ કરો (TTY: 711).

Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na

mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong
nasa iyong ID Card (TTY: 711).

Japanese/日本語: お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご
利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください
（TTY: 711）。

German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche

Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an
(TTY: 711).

Persian/‫پارسیان‬:
‫ با شمار تلفن مندرج بر روی کارت شناسایی‬.‫ خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد‬،‫ اگر زبان شما فارسی است‬:‫توج‬

.(TTY: 711) ‫خود با بخش «خدمات اعضا» تماس بگیر ید‬
່ໍLບaເoສ/ຍພຄ່ າາສ.າໂລທາຫວາ:ຝໍ່ຂ້ າຄຍວໍບນິລໃກສ່ າໃຈນ:ສຖະ້ ມາເາົຈ້ິຊາກເົວ່ີທ້ າໝພາາສຍາເລລາກວໂໄທດ້ ລ, ະີມສັ ກບາຢູ່ ນໃໍບນິລບັ ກດາຂນອຊ່ ງວທ່ ຍາເນືຫຼ (ອTTດ້ Yາ:ນ7ພ11າ)ສ. າໃຫ້ ທ່ ານໂດຍ
Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47
t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’
b44sh bee hod77lnih (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue CrossBlue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross

and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
000893531 and Blue Shield of Massachusetts HMO Blue, Inc. 55-2066-22 (6/21)164711MB
55-1493 (8/16)

OUR COMMITMENT TO CONFIDENTIALITY

This Notice describes how medical information about you may be
used and disclosed, and how you can get access to this information.
Please review it carefully.

Our Commitment: We respect your right to privacy.
We won’t disclose personally identifiable information about you
without your permission, unless the disclosure is necessary to provide
our services to you or is otherwise in accordance with the law.

Collection of Information
We collect only personal or medical information we need to carry out our business.
• Examples of personal information are name, address, date of birth, and social

security number. Most often, you and your employer supply this information to
enroll you in a plan.
• Examples of medical information are diagnoses, treatments, and names of providers
who treat you. Most often, your providers supply this information.

Use and Disclosure of Information

We’re required by law to protect the confidentiality of your personal and medical information
and to notify you in case of a breach affecting your personal or medical information. We’ll supply
your information to you upon your request or to help you understand treatment options and
other benefits available to you.
We also may use and disclose your information without your written authorization for the
following purposes, and as otherwise permitted or required by law:
• Treatment—to help providers manage or coordinate your health care and related services.

For example, to refer you to another provider or remind you of appointments.
• Payment—to obtain payment for your coverage, provide you with health benefits, and assist

another health plan or provider in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or coordinate benefits with other
coverage you may have.

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

• Health Care Operations—to operate our business, including accreditation, credentialing,
customer service, disease management, and fraud-prevention activities. For example,
to do business planning, arrange for medical review, or conduct quality assessment and
improvement activities.

• Legal Compliance—to comply with applicable laws. For example, to respond to regulatory
authorities responsible for oversight of government benefit programs or our operations; to
parties or courts in the course of judicial or administrative proceedings; to law enforcement
officials during an investigation; and as necessary to comply with workers’ compensation laws.

• Research and Public Health—for medical research studies in accordance with laws for
the protection of human research subjects, and to report to public health authorities and
otherwise prevent or lessen a serious and imminent threat to health or safety. For example,
for the purpose of preventing or controlling disease, injury, or disability.

• To an Account (such as an employer) or Party It Designates—for administration of its
health plan. For example, to a self-insured account for claim review and audits. We’ll disclose
your information only to designated individuals. That, along with contract obligations, helps
protect your information from unauthorized use.

To carry out these purposes, we share information with entities that perform functions for us
subject to contracts that limit use and disclosure to intended purposes. We use physical,
electronic, and procedural safeguards to protect your privacy. Even when allowed, uses and
disclosures are limited to the minimum amount reasonably necessary for the intended task.

Special Notes Regarding Disclosure

Special protections apply to information about certain medical conditions. For example,
with very few exceptions allowed by law, we won’t disclose any information regarding HIV
or AIDS to any party without your written permission. We won’t disclose mental health
treatment records to you without first receiving approval from your treating provider
or another equally qualified mental health professional. Also, we’re prohibited from using
or disclosing genetic information for underwriting purposes.
Except as provided in this notice, we won’t use or disclose your personal or medical information
without your written authorization. A form for this purpose is available on our website or by
calling Member Service. Specifically, we must have your written authorization to use or disclose
your information for:
• Marketing purposes;
• The sale of PHI;
• Most use and disclosures of psychotherapy notes.

You may revoke your authorization at any time. Your authorization must be in writing.
Your revocation won’t affect any action that we have already taken in reliance on
your authorization.

Your Privacy Rights

You have the following rights with respect to your personal and medical information.
To exercise any of these rights, contact us using the information listed at the end of this notice.

• You have the right to receive information about privacy protections. Your member-
education materials include a notice of your rights, and you may request a paper copy
of this notice at any time.

• You have the right to inspect and get copies of information we collect about you.
We’ll provide access to this information within 30 days of receiving a written request.
We may charge a reasonable fee for copying and mailing records. You may also ask your
providers for access to your records.

• You have the right to receive an accounting of disclosures. Your request must be in writing.
Our response will exclude any disclosures made in support of treatment, payment, and
health care operations or that you authorized (among others). An example of a disclosure
that would be reported to you is a disclosure of your information in response to a subpoena.

• You have the right to ask us to correct or amend information you believe to be incorrect.
Your request to correct, amend, or delete information should be in writing. We’ll notify
you if we make an adjustment as a result of your request. If we don’t make an adjustment,
we’ll send you a letter explaining why within 30 days. In this case, you may ask us to make
your request part of your records, or ask the commissioner of insurance to review our
decision. We may also provide notice of your requested changes to others who received
this information in the past two years.

• You have the right to designate someone to receive information and interact with
us on your behalf. Your personal representative has the same rights concerning your
information as you. Your designation and any subsequent revocation must be in writing,
and a form for this purpose is available on our website or by calling Member Service.

• You have the right to ask that we restrict or refuse to disclose personally identifiable
information, and that we direct communications to you by alternative means or to
alternative locations. While we may not always be able to agree, we’ll make reasonable
efforts to accommodate requests. Your request and any subsequent revocation must
be in writing.

• If you believe your privacy rights have been violated, you have the right to complain
to us, using the standard grievance process outlined in your benefit materials, or to
the secretary of the U.S. Department of Health and Human Services, without fear
of retaliation.

About This Notice

This notice is effective September 23, 2013. We’re required by law to provide this notice
to you and to abide by it while it is in effect. We reserve the right to change this notice.
Any changes will apply to all personal and medical information that we maintain, regardless
of when it was created or received. Before we make any material changes in our privacy
practices, we’ll post a new notice on our website. We’ll provide information about the
changes to our privacy practices and how to obtain a new notice in our next annual mailing
to members who are then covered by one of our health plans.
If you have any questions, contact Member Service. We’re here to help. Please call the
Member Service toll-free number on your ID card or visit our website at bluecrossma.org.

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or
Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000892855 Y0014_18157_C 37-0830-22 (9/21)

04

Enrollment



Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP) 2022

ENROLLMENT FORM

Who can use this form? What happens next?

People with Medicare who want to join Send your completed and signed form to:
a Medicare Prescription Drug Plan Blue MedicareRx
P.O. Box 30001
To join a plan, you must: Pittsburgh, PA 15222-0330
• Be a United States citizen or be Once we process your request to join,
we'll contact you.
lawfully present in the United States.
• Live in the plan’s service area

When do I use this form? Contact Us:

You can join a plan: Connecticut Residents:
• Between October 15–December 7 each year 1-866-832-9702 (TTY: 711)
24 hours a day, 7 days a week
(for coverage starting January 1)
• Within three months of first getting Medicare Massachusetts Residents:
• In certain situations where you’re allowed to 1-800-678-2265 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
join or switch plans 4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
Visit medicare.gov to learn more about when
you can sign up for a plan. Rhode Island Residents:
1-800-505-2583 (TTY: 711)
What do I need to complete this form? 10/1-3/31, 7 days a week, 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.
• Your Medicare Number (the number on your You can use our automated answering system outside
red, white, and blue Medicare card) of these hours.

• Your permanent address and phone number

Note: You must complete all items in Section 1. The items
in Section 2 are optional — you can’t be denied coverage
because you don’t fill them out.

Reminders: Vermont Residents:
1-888-496-4178 (TTY: 711)
• If you want to join a plan during Fall open 24 hours a day, 7 days a week
enrollment (October 15–December 7), the
plan must get your completed form by Or, call Medicare at 1-800-MEDICARE
December 7. (1-800-633-4227). TTY users can call
1-877-486-2048.
• Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.

Independent Licensees of the Blue Cross and Blue Shield Association.

S2893_2123_C OMB No. 0938-1378 Expires: 7/31/2023

Section 1 – All fields on this page are required (unless marked optional) 2022

Select the 2022 plan you want to join:

q Blue MedicareRx Value Plus: $51.70 per month q Blue MedicareRx Premier: $136.20 per month
Optional: Middle Initial:
FIRST name: LAST name:

Birth date: Sex: Phone number:
()
(MM/DD/YYYY) (__ __/__ __/__ __ __ __) q Male q Female -

Permanent Residence street address (Don’t enter a PO Box):

Street address: City: State: ZIP Code:

Mailing address, if different from your permanent address (PO Box allowed):

Street address: City: State: ZIP Code:

Your Medicare information:

Medicare Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Answer these important questions:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Blue MedicareRx? q Yes q No

Name of other coverage: Member number for this coverage: Group number for this coverage:

IMPORTANT: Read and sign below:

• I must keep Hospital (Part A) or Medical (Part B) to stay in Blue MedicareRx.
• By joining this Medicare Prescription Drug Plan, I acknowledge that Blue MedicareRx will share my information with

Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by federal law
that authorize the collection of this information (see Privacy Act Statement below).
• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
• 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'll be disenrolled from the plan.
• I understand that people with Medicare are generally not covered under Medicare while out of the country,
except for limited coverage near the United States border.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application
means that I have read and understand the contents of this application. If signed by an authorized representative (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’re the authorized representative, sign above and fill out these fields:

Name: Phone number:

Street address: Relationship to enrollee:

Section 1A – Enrollment Eligibility 2022

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’re certifying that, to the best of your

knowledge, you’re eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be
disenrolled. Please check all that apply and include applicable date in the designated space for each section.

q I’m applying during the Annual Enrollment period I’m new to Medicare.
(October 15 through December 7) for an effective
date of January 1. q 65th Birthday

Medicare Assistance Programs q Disability Determination

q I recently had a change in my Medicaid (new recipient q Existing Medicare (via disability)–now turning 65
of Medicaid; had a change in level of Medicaid Insert Date: ( __ __ /__ __ /__ __ __ __)
assistance; or lost Medicaid) on:
(M M/ D D/ Y Y Y Y)
q I recently had a change in my Extra Help paying for
Medicare prescription drug coverage (new recipient I involuntarily lost coverage.
of Extra Help; had a change in the level of Extra Help;
or lost Extra Help) on: q I recently involuntarily lost my creditable prescription
drug coverage (as good as Medicare’s) on:
q I have both Medicare and Medicaid (or my state
helps pay for my Medicare premiums) or I receive q My plan is ending its contract with Medicare,
Extra Help paying for my Medicare prescription drug or Medicare is ending its contract with my plan on:
coverage, but I haven’t had a change. I’m making this
enrollment request between January 1 and September Insert Date: ( __ __ /__ __ /__ __ __ __)
30 and I understand I can only make this request
once per quarter. (M M/ D D/ Y Y Y Y)

q I belong to a pharmacy assistance program provided Miscellaneous reasons
by my state.
q I was enrolled in a plan by Medicare (or my state)
q I recently left a PACE program on: and I want to choose a different plan.

q I live in or recently moved out of a long-term care q I was affected by an emergency or major disaster (as
facility (for example, a nursing home). I moved/will directed by the Federal Emergency Management Agency
move into/out of the facility on: (FEMA) or by a federal, state, or local government entity).
One of the other statements here applied to me, but
Insert Date: ( __ __ /__ __ /__ __ __ __) I was unable to make my enrollment because of the
disaster.
(M M/ D D/ Y Y Y Y)
q I’m leaving employer or union group coverage on:
Change in Residence
q I’m enrolled in a Medicare Advantage plan and want
q I recently moved outside of the service area for my to make a change during the Medicare Advantage
current plan, or I recently moved and this plan is a Open Enrollment Period (MA OEP) between January 1
new option for me. I moved on: and March 31.

q I recently returned to the United States after living q Individuals Enrolled in a Plan Placed in Receivership
permanently outside of the United States.
I returned to the United States on: q Individuals Enrolled in a Plan that has been identified
by Centers for Medicare & Medicaid Services (CMS)
q I recently obtained lawful presence status as a Consistent Poor Performer
in the United States. I received this status on:
q [I’m enrolling in a 5-STAR Medicare Prescription
q I recently was released from incarceration. Drug Plan.]
I was released on:
Insert Date: ( __ __ /__ __ /__ __ __ __)
Insert Date: ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
(M M/ D D/ Y Y Y Y)
Other

q Other Explain: ______________________

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

Section 2 – All fields on this page are optional. 2022

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select if you want us to send you information in an accessible format. q Large print

Please contact Blue MedicareRx at the phone number listed on the front page if you need information
in an accessible format other than what is listed above.

Do you work? q Yes q No Does your spouse work? q Yes q No

List your Primary Care Provider (PCP), clinic, or health center:

Paying your plan premiums

You can pay your monthly plan premium by mail, electronic funds transfer (EFT), which is an automatic withdrawal from
your bank account, or credit card each month. You can also choose to pay your premium by having it automatically taken
out of your Social Security or Railroad Retirement Board (RRB) benefit each month. If you have to pay a Part D-Income
Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium.
The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T
pay Blue MedicareRx the Part D-IRMAA.

Please select a premium payment option:
q Receive a bill

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

q 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. q Checking q Savings (check one)

Name on Account

Financial Institution

Routing Number

Account Number
Account Holder Signature __________________________

VOID

1234567890 12 34567890

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.

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.

Broker Box for Connecticut and Rhode Island Only: 2022

Medicare Prescription Drug Plan Office & Producer Use Only:
Date Application Received by Agent/Broker/Rep:
Effective Date of Coverage:
Enrollment Period Type: q IEP q AEP q 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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-NEW. The time required to complete this information
is estimated to average 20 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
IMPORTANT: Do not send this form or any items with your personal information (such as claims,
payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that
aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378)
will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?”
on the first page of this document when you send your completed form to the plan.
Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value
Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to
service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross &
Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which
have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and
are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-
approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Privacy Act Statement:
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to
track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve
care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security
Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information.
CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified
in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx),” System
No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect
enrollment in the plan.

® Registered Marks of the Blue Cross and Blue Shield Association.
®´ Registered Marks are the property of their respective owners. © 2021 All Rights Reserved.

000844747 ENRF-22 55-2043-22 (9/21)

Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP) 2022

ENROLLMENT FORM

Who can use this form? What happens next?

People with Medicare who want to join Send your completed and signed form to:
a Medicare Prescription Drug Plan Blue MedicareRx
P.O. Box 30001
To join a plan, you must: Pittsburgh, PA 15222-0330
• Be a United States citizen or be Once we process your request to join,
we'll contact you.
lawfully present in the United States.
• Live in the plan’s service area

When do I use this form? Contact Us:

You can join a plan: Connecticut Residents:
• Between October 15–December 7 each year 1-866-832-9702 (TTY: 711)
24 hours a day, 7 days a week
(for coverage starting January 1)
• Within three months of first getting Medicare Massachusetts Residents:
• In certain situations where you’re allowed to 1-800-678-2265 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
join or switch plans 4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
Visit medicare.gov to learn more about when
you can sign up for a plan. Rhode Island Residents:
1-800-505-2583 (TTY: 711)
What do I need to complete this form? 10/1-3/31, 7 days a week, 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.
• Your Medicare Number (the number on your You can use our automated answering system outside
red, white, and blue Medicare card) of these hours.

• Your permanent address and phone number

Note: You must complete all items in Section 1. The items
in Section 2 are optional — you can’t be denied coverage
because you don’t fill them out.

Reminders: Vermont Residents:
1-888-496-4178 (TTY: 711)
• If you want to join a plan during Fall open 24 hours a day, 7 days a week
enrollment (October 15–December 7), the
plan must get your completed form by Or, call Medicare at 1-800-MEDICARE
December 7. (1-800-633-4227). TTY users can call
1-877-486-2048.
• Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.

Independent Licensees of the Blue Cross and Blue Shield Association.

S2893_2123_C OMB No. 0938-1378 Expires: 7/31/2023

Section 1 – All fields on this page are required (unless marked optional) 2022

Select the 2022 plan you want to join:

q Blue MedicareRx Value Plus: $51.70 per month q Blue MedicareRx Premier: $136.20 per month
Optional: Middle Initial:
FIRST name: LAST name:

Birth date: Sex: Phone number:
()
(MM/DD/YYYY) (__ __/__ __/__ __ __ __) q Male q Female -

Permanent Residence street address (Don’t enter a PO Box):

Street address: City: State: ZIP Code:

Mailing address, if different from your permanent address (PO Box allowed):

Street address: City: State: ZIP Code:

Your Medicare information:

Medicare Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Answer these important questions:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Blue MedicareRx? q Yes q No

Name of other coverage: Member number for this coverage: Group number for this coverage:

IMPORTANT: Read and sign below:

• I must keep Hospital (Part A) or Medical (Part B) to stay in Blue MedicareRx.
• By joining this Medicare Prescription Drug Plan, I acknowledge that Blue MedicareRx will share my information with

Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by federal law
that authorize the collection of this information (see Privacy Act Statement below).
• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
• 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'll be disenrolled from the plan.
• I understand that people with Medicare are generally not covered under Medicare while out of the country,
except for limited coverage near the United States border.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application
means that I have read and understand the contents of this application. If signed by an authorized representative (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’re the authorized representative, sign above and fill out these fields:

Name: Phone number:

Street address: Relationship to enrollee:

Section 1A – Enrollment Eligibility 2022

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’re certifying that, to the best of your

knowledge, you’re eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be
disenrolled. Please check all that apply and include applicable date in the designated space for each section.

q I’m applying during the Annual Enrollment period I’m new to Medicare.
(October 15 through December 7) for an effective
date of January 1. q 65th Birthday

Medicare Assistance Programs q Disability Determination

q I recently had a change in my Medicaid (new recipient q Existing Medicare (via disability)–now turning 65
of Medicaid; had a change in level of Medicaid Insert Date: ( __ __ /__ __ /__ __ __ __)
assistance; or lost Medicaid) on:
(M M/ D D/ Y Y Y Y)
q I recently had a change in my Extra Help paying for
Medicare prescription drug coverage (new recipient I involuntarily lost coverage.
of Extra Help; had a change in the level of Extra Help;
or lost Extra Help) on: q I recently involuntarily lost my creditable prescription
drug coverage (as good as Medicare’s) on:
q I have both Medicare and Medicaid (or my state
helps pay for my Medicare premiums) or I receive q My plan is ending its contract with Medicare,
Extra Help paying for my Medicare prescription drug or Medicare is ending its contract with my plan on:
coverage, but I haven’t had a change. I’m making this
enrollment request between January 1 and September Insert Date: ( __ __ /__ __ /__ __ __ __)
30 and I understand I can only make this request
once per quarter. (M M/ D D/ Y Y Y Y)

q I belong to a pharmacy assistance program provided Miscellaneous reasons
by my state.
q I was enrolled in a plan by Medicare (or my state)
q I recently left a PACE program on: and I want to choose a different plan.

q I live in or recently moved out of a long-term care q I was affected by an emergency or major disaster (as
facility (for example, a nursing home). I moved/will directed by the Federal Emergency Management Agency
move into/out of the facility on: (FEMA) or by a federal, state, or local government entity).
One of the other statements here applied to me, but
Insert Date: ( __ __ /__ __ /__ __ __ __) I was unable to make my enrollment because of the
disaster.
(M M/ D D/ Y Y Y Y)
q I’m leaving employer or union group coverage on:
Change in Residence
q I’m enrolled in a Medicare Advantage plan and want
q I recently moved outside of the service area for my to make a change during the Medicare Advantage
current plan, or I recently moved and this plan is a Open Enrollment Period (MA OEP) between January 1
new option for me. I moved on: and March 31.

q I recently returned to the United States after living q Individuals Enrolled in a Plan Placed in Receivership
permanently outside of the United States.
I returned to the United States on: q Individuals Enrolled in a Plan that has been identified
by Centers for Medicare & Medicaid Services (CMS)
q I recently obtained lawful presence status as a Consistent Poor Performer
in the United States. I received this status on:
q [I’m enrolling in a 5-STAR Medicare Prescription
q I recently was released from incarceration. Drug Plan.]
I was released on:
Insert Date: ( __ __ /__ __ /__ __ __ __)
Insert Date: ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
(M M/ D D/ Y Y Y Y)
Other

q Other Explain: ______________________

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

Section 2 – All fields on this page are optional. 2022

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select if you want us to send you information in an accessible format. q Large print

Please contact Blue MedicareRx at the phone number listed on the front page if you need information
in an accessible format other than what is listed above.

Do you work? q Yes q No Does your spouse work? q Yes q No

List your Primary Care Provider (PCP), clinic, or health center:

Paying your plan premiums

You can pay your monthly plan premium by mail, electronic funds transfer (EFT), which is an automatic withdrawal from
your bank account, or credit card each month. You can also choose to pay your premium by having it automatically taken
out of your Social Security or Railroad Retirement Board (RRB) benefit each month. If you have to pay a Part D-Income
Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium.
The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T
pay Blue MedicareRx the Part D-IRMAA.

Please select a premium payment option:
q Receive a bill

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

q 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. q Checking q Savings (check one)

Name on Account

Financial Institution

Routing Number

Account Number
Account Holder Signature __________________________

VOID

1234567890 12 34567890

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.

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.

Broker Box for Connecticut and Rhode Island Only: 2022

Medicare Prescription Drug Plan Office & Producer Use Only:
Date Application Received by Agent/Broker/Rep:
Effective Date of Coverage:
Enrollment Period Type: q IEP q AEP q 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

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-NEW. The time required to complete this information
is estimated to average 20 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
IMPORTANT: Do not send this form or any items with your personal information (such as claims,
payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that
aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378)
will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?”
on the first page of this document when you send your completed form to the plan.
Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value
Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to
service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross &
Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which
have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and
are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-
approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Privacy Act Statement:
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to
track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve
care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security
Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information.
CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified
in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx),” System
No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect
enrollment in the plan.

® Registered Marks of the Blue Cross and Blue Shield Association.
®´ Registered Marks are the property of their respective owners. © 2021 All Rights Reserved.

000844747 ENRF-22 55-2043-22 (9/21)



 Medicare Plan Sales:

FOR MORE 1-800-678-2265 (TTY: 711)
INFORMATION, October 1 through March 31,
OR TO ENROLL: 8:00 a.m. - 8:00 p.m. ET, seven days a week
April 1 through September 30,
8:00 a.m. - 8:00 p.m. ET, Monday through Friday
bluecrossma.com/Medicare

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.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços
linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

000893320 99-0651-22 (9/21)