BCBSMA PDP_SalesKit Book 12/01/2020 Approved By Angela Gagnon 11/25/2020 2:22 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 ្MរបយOត័ N�៖-្KរបសHិនMេបEើអRក� ន,យិ C‌AយMភាសBា㏸OែខDរ� IេសANវ‌ជំនួយែផ�កភាសា㏸េដ‌យមិនគតិ ឈល�
‫ 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 ‍ចរកបានសរំ ‌ប់អ�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 सेवाएं मफु ्त 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_C 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)

PN-MA-21

04

Enrollment



Blue MedicareRx (PDP)

Who can use this form? What do I need to complete this form?

People with Medicare who want to join a • Your Medicare Number (the number on your
Medicare Prescription Drug Plan red, white, and blue Medicare card)

To join a plan, you must: • Your permanent address and phone number
• Be a United States citizen or be
Note: You must complete all items in Section 1. The items
lawfully present in the U.S. in Section 2 are optional — you can’t be denied coverage
• Live in the plan’s service area because you don’t fill them out.

When do I use this form? Reminders:

You can join a plan: • If you want to join a plan during fall open
• Between October 15–December 7 each year enrollment (October 15–December 7), the
plan must get your completed form by
(for coverage starting January 1) December 7.
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to • Your plan will send you a bill for the plan’s
premium. You can choose to sign up to
join or switch plans have your premium payments deducted
Visit medicare.gov to learn more about when from your bank account or your monthly
you can sign up for a plan. Social Security (or Railroad Retirement
Board) benefit.

What happens next?

Send your completed and signed form to:
Blue MedicareRx
P.O. Box 30001
Pittsburgh, PA 15222-0330
Once they process your request to join, they’ll contact you.

How do I get help with this form?

Connecticut Residents: Rhode Island Residents:
1-866-832-9702 (TTY: 711) 1-800-505-2583 (TTY: 711)

24 hours a day, 7 days a week 4/1-9/30, 8:00 a.m. to 8:00 p.m. ET, Monday - Friday.
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week.
Massachusetts Residents: You can use our automated answering system outside
1-800-678-2265 (TTY: 711) of these hours.
4/1-9/30, 8:00 a.m. to 8:00 p.m. ET, Monday - Friday.
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week. Vermont Residents:

1-888-496-4178 (TTY: 711)

24 hours a day, 7 days a week

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Independent licensees of the Blue Cross and Blue Shield Association. OMB No. 0938-1378 Expires:7/31/2023
S2893_2030_C

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

Select the plan you want to join:

Blue MedicareRx Value Plus: $50.50 per month Blue MedicareRx Premier: $135.00 per month

FIRST name: LAST name: Optional: Middle Initial:

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

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

City: Optional: County: 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? Yes 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 will 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 U.S. 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: Address:

Phone number: Relationship to enrollee:

Section 1A: 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’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.

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. 65th Birthday

Medicare Assistance Programs Disability Determination

I recently had a change in my Medicaid (new recipient Existing Medicare (via disability)–now turning
of Medicaid; had a change in level of Medicaid 65 on (insert date):
assistance; or lost Medicaid) on ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
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 I recently involuntarily lost my creditable prescription
drug coverage (as good as Medicare’s) on:
I have both Medicare and Medicaid (or my state
helps pay for my Medicare premiums) or I receive 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
coverage, but I haven’t had a change. I’m making this on: (insert date):
enrollment request between January 1 and September ( __ __ /__ __ /__ __ __ __)
30 and I understand I can only make this request (M M/ D D/ Y Y Y Y)
once per quarter.
Miscellaneous reasons
I belong to a pharmacy assistance program provided
by my state. I was enrolled in a plan by Medicare (or my state)
and I want to choose a different plan.
I recently left a PACE program on
I was affected by a Government Entity-Declared
I live in or recently moved out of a Long-Term Care Disaster or Other Emergency. One of the other
Facility (for example, a nursing home). I moved/will statements here applied to me, but I was unable to
move into/out of the facility on (insert date): make my enrollment because of the natural disaster.
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y) I’m leaving employer or union group coverage on

Change in Residence I’m enrolled in a Medicare Advantage plan and want
to make a change during the Medicare Advantage
I recently moved outside of the service area for my Open Enrollment Period (MA OEP) between January 1
current plan, or I recently moved and this plan is a and March 31.(insert date):
new option for me. I moved on: ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
I recently returned to the United States after living
permanently outside of the United States. Other
I returned to the U.S. on
Other Explain: ______________________
I recently obtained lawful presence status
in the United States. I received this status on

I recently was released from incarceration.
I was released on (insert date):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

If none of these statements applies 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

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. 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’s listed above.

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

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

Paying your plan premiums

You can pay your monthly plan premium by mail, Electronic Funds Transfer (EFT), 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:
Receive a bill Automatic Bank Withdrawal (EFT) or credit card
Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check

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.

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

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 this page to 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.

®Registered Marks of the Blue Cross and Blue Shield Association.
®´ Registered Marks are the property of their respective owners. © 2020 All Rights Reserved.

000412974 ENRF-21 55-2043-21 (9/20)

Blue MedicareRx (PDP)

Who can use this form? What do I need to complete this form?

People with Medicare who want to join a • Your Medicare Number (the number on your
Medicare Prescription Drug Plan red, white, and blue Medicare card)

To join a plan, you must: • Your permanent address and phone number
• Be a United States citizen or be
Note: You must complete all items in Section 1. The items
lawfully present in the U.S. in Section 2 are optional — you can’t be denied coverage
• Live in the plan’s service area because you don’t fill them out.

When do I use this form? Reminders:

You can join a plan: • If you want to join a plan during fall open
• Between October 15–December 7 each year enrollment (October 15–December 7), the
plan must get your completed form by
(for coverage starting January 1) December 7.
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to • Your plan will send you a bill for the plan’s
premium. You can choose to sign up to
join or switch plans have your premium payments deducted
Visit medicare.gov to learn more about when from your bank account or your monthly
you can sign up for a plan. Social Security (or Railroad Retirement
Board) benefit.

What happens next?

Send your completed and signed form to:
Blue MedicareRx
P.O. Box 30001
Pittsburgh, PA 15222-0330
Once they process your request to join, they’ll contact you.

How do I get help with this form?

Connecticut Residents: Rhode Island Residents:
1-866-832-9702 (TTY: 711) 1-800-505-2583 (TTY: 711)

24 hours a day, 7 days a week 4/1-9/30, 8:00 a.m. to 8:00 p.m. ET, Monday - Friday.
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week.
Massachusetts Residents: You can use our automated answering system outside
1-800-678-2265 (TTY: 711) of these hours.
4/1-9/30, 8:00 a.m. to 8:00 p.m. ET, Monday - Friday.
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week. Vermont Residents:

1-888-496-4178 (TTY: 711)

24 hours a day, 7 days a week

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Independent licensees of the Blue Cross and Blue Shield Association. OMB No. 0938-1378 Expires:7/31/2023
S2893_2030_C

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

Select the plan you want to join:

Blue MedicareRx Value Plus: $50.50 per month Blue MedicareRx Premier: $135.00 per month

FIRST name: LAST name: Optional: Middle Initial:

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

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

City: Optional: County: 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? Yes 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 will 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 U.S. 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: Address:

Phone number: Relationship to enrollee:

Section 1A: 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’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.

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. 65th Birthday

Medicare Assistance Programs Disability Determination

I recently had a change in my Medicaid (new recipient Existing Medicare (via disability)–now turning
of Medicaid; had a change in level of Medicaid 65 on (insert date):
assistance; or lost Medicaid) on ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
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 I recently involuntarily lost my creditable prescription
drug coverage (as good as Medicare’s) on:
I have both Medicare and Medicaid (or my state
helps pay for my Medicare premiums) or I receive 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
coverage, but I haven’t had a change. I’m making this on: (insert date):
enrollment request between January 1 and September ( __ __ /__ __ /__ __ __ __)
30 and I understand I can only make this request (M M/ D D/ Y Y Y Y)
once per quarter.
Miscellaneous reasons
I belong to a pharmacy assistance program provided
by my state. I was enrolled in a plan by Medicare (or my state)
and I want to choose a different plan.
I recently left a PACE program on
I was affected by a Government Entity-Declared
I live in or recently moved out of a Long-Term Care Disaster or Other Emergency. One of the other
Facility (for example, a nursing home). I moved/will statements here applied to me, but I was unable to
move into/out of the facility on (insert date): make my enrollment because of the natural disaster.
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y) I’m leaving employer or union group coverage on

Change in Residence I’m enrolled in a Medicare Advantage plan and want
to make a change during the Medicare Advantage
I recently moved outside of the service area for my Open Enrollment Period (MA OEP) between January 1
current plan, or I recently moved and this plan is a and March 31.(insert date):
new option for me. I moved on: ( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)
I recently returned to the United States after living
permanently outside of the United States. Other
I returned to the U.S. on
Other Explain: ______________________
I recently obtained lawful presence status
in the United States. I received this status on

I recently was released from incarceration.
I was released on (insert date):
( __ __ /__ __ /__ __ __ __)
(M M/ D D/ Y Y Y Y)

If none of these statements applies 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

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. 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’s listed above.

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

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

Paying your plan premiums

You can pay your monthly plan premium by mail, Electronic Funds Transfer (EFT), 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:
Receive a bill Automatic Bank Withdrawal (EFT) or credit card
Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check

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.

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

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 this page to 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.

®Registered Marks of the Blue Cross and Blue Shield Association.
®´ Registered Marks are the property of their respective owners. © 2020 All Rights Reserved.

000412974 ENRF-21 55-2043-21 (9/20)



FOR MORE INFORMATION, OR TO ENROLL:

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week
April 1 through September 30, 8:00 a.m. to 8:00 p.m., 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.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

000404172 (1(92//2001)/20)