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Paying Your Plan Premium 4. Are you a resident in a long-term care facility, such as a nursing home? Yes No
You can pay your monthly plan premium (including any late enrollment penalty that Please select a If “yes”, please provide the following information: Name & Address of Institution
you currently have or may owe) by mail, Electronic Funds Transfer (EFT), or you can premium payment option: Phone Number of Institution
also choose to pay your premium by automatic deduction from your Social Security Get a bill monthly
or Railroad Retirement Board (RRB) benefit check each month. 5. Are you enrolled in your State If “yes”, please provide your Medicaid Number: Yes No
Electronic Funds Transfer (EFT) from Medicaid program?
If you are assessed a Part D-Income Related Monthly Adjustment Amount (IRMAA), your bank account each month. We will
you will be notified by the Social Security Administration. You will be responsible for send you a brochure and form to enroll. 6. Do you or your spouse work? Yes No
paying this extra amount in addition to your plan premium. You will either have the (Please pay your premium by mail until
amount withheld from your Social Security benefit check or be billed directly by Medicare you receive notification that your EFT 7. Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15
or RRB. DO NOT pay Medicare HMO Blue ValueRx/FlexRx/PlusRx the Part D-IRMAA. payment option is activated.) through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside

People with limited incomes may qualify for extra help to pay for their prescription Automatic deduction from your monthly of this period.
drug costs. If you’re eligible, Medicare could pay for 75% or more of your drug costs, Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following
including monthly prescription drug premiums, annual deductibles, and co-insurance. Social Security or boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that
Additionally, those who qualify will not be subject to the coverage gap or a late Railroad Retirement Board this information is incorrect, you may be disenrolled. Please check any statement below that is true for you. We may contact you
enrollment penalty. Many people are eligible for these savings and don’t even know it. (RRB) benefit check for additional information.
For more information about this extra help, contact your local Social Security office, or I am new to Medicare I recently involuntarily lost my creditable drug coverage
call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. (The Social Security/RRB deduction (coverage as good as Medicare’s). I lost my drug coverage
You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp. may take two or more months to begin I recently moved outside of the service area for my current
after Social Security or RRB approves plan or I recently moved and this plan is a new option for me. on (insert date) _________________________________ .
If you qualify for extra help with your Medicare prescription drug coverage costs, the deduction. In most cases, if Social I moved on (insert date) I am leaving employer or union coverage on
Medicare will pay all or part of your plan premium. If Medicare pays only a portion of Security or RRB accepts your request for ____________________________________________ . (insert date) ___________________________________ .
this premium, we will bill you for the amount that Medicare doesn’t cover. automatic deduction, the first deduction I recently returned to the United States after living I belong to a pharmacy assistance program provided by

If you don’t select a payment option, you will get a bill each month. from your Social Security or RRB benefit permanently outside of the U.S. I returned to the U.S. my state.
check will include all premiums due from on (insert date)_________________________________ .
your enrollment effective date up to the My plan, (insert name) ________________________,
point withholding begins. If Social Security I have both Medicare and Medicaid or my state helps pay is ending its contract with Medicare, or Medicare is ending
or RRB does not approve your request for for my Medicare premiums. its contract with my plan effective (insert date)
automatic deduction, we will send you a I get extra help paying for Medicare prescription ____________________________________________ .
paper bill for your monthly premiums.) drug coverage. I was enrolled in a Special Needs Plan (SNP), but I have lost
the special needs qualification required to be in that plan.
I no longer qualify for extra help paying for Medicare
prescription drugs I stopped receiving extra help on I was disenrolled from the SNP on (insert date)
(insert date)___________________________________ . ____________________________________________ .

Please Read and Answer These Important Questions I am moving into, live in or recently moved out of a I am enrolling in a 5 Star Medicare Plan.
1. Do you have End Stage Renal Disease (ESRD)? Yes No Long-Term Care Facility (for example, a nursing home or a If none of these statements applies to you or you’re not sure,
rehabilitation hospital). I moved/will move into/out of the facility please contact Member Service at the number listed below
If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach on (insert date)__________________________________ . to see if you are eligible to enroll
a note or records from your doctor showing you have had a successful kidney transplant or you don’t need
dialysis, otherwise we may need to contact you to obtain additional information. I recently “left” a PACE program on (insert date) If you would prefer us to send you information in
____________________________________________ . large print or braille please contact Member Service at the
2. Some individuals may have other drug coverage, If “yes,” please Name of other coverage Yes No number listed below.
including other private insurance, TRICARE, Federal list your other Please list your PCP’s ID Number: Yes No
employee health benefits coverage, VA benefits, or state coverage and your Please choose the name of a Primary Care Provider (PCP):
pharmaceutical assistance programs. identification (ID) ID# for this coverage Are you a current patient?
Will you have other prescription drug coverage in number(s) for this Questions? Contact Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET, Monday–Friday, from Feb. 15
addition to Medicare HMO Blue ValueRx/FlexRx/PlusRx? coverage Group# for this coverage to Sept. 30; and 8:00 a.m. to 8:00 p.m. ET, 7 days a week, from Oct. 1 to Feb. 14.

STOP Please Read This Important Information STOP
3. Do you, either on your own or through your spouse, have any health coverage other than Medicare, Yes No
such as private insurance? If you currently have health coverage from an employer or union, joining Medicare HMO Blue ValueRx/FlexRx/PlusRx could
affect your employer or union health benefits. You could lose your employer or union health coverage if you join Medicare
What kind of coverage? Name of your insurance company HMO Blue ValueRx/FlexRx/PlusRx. 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 any information on whom to contact, your benefits
administrator or the office that answers questions about your coverage can help.

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