I want to transfer from my current plan to the plan I have selected below. I understand that if this
form is received by the end of any month, my new plan will generally be effective the 1st of the
Paying Your Plan Premium
If you enroll in a zero premium plan - You must continue to pay your Part A (if applicable) and/or Part B premium. The next question may seem odd since you’re enrolling into a $0 premium plan, but we need to know how you would like to pay if there was ever a premium such as for a late enrollment penalty. If we determined that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by automatic deduction from your Social Security (SSA) or Railroad Retirement Board (RRB) benefit check, Electronic Funds Transfer (EFT) from your bank, Credit card, Debit card, or check via mail. If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by SSA. You will be responsible for paying this extra amount in addition to your monthly charges. You will either have the amount withheld from your SSA benefit check or be billed directly by Medicare or the RRB. DO NOT pay Blue Advantage the Part D-IRMAA.
If you enroll in a plan with a premium - You must continue to pay your Part A (if applicable) and/or Part B premium. We will not collect any premium at this time but after application submission, you have the option to set up a monthly auto-pay from your account starting the month your plan goes into effect. You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, Electronic Funds Transfer (EFT), or credit card each month. You can also choose to pay your premium by automatic deduction from your Social Security (SSA) or Railroad Retirement Board (RRB) benefit check, each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Blue Advantage the Part D-IRMAA.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1 (800) 772-1213. TTY users should call 1 (800) 325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.
The fields in this section are optional.
Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
Please contact Blue Advantage toll-free at 1-800-232-4967 (TTY 711) if you need information in large print or Spanish. Member Services is available seven days a week, 8:00 a.m. – 8:00 p.m. CST from October through March, and available five days a week, 8:00 a.m. – 8:00 p.m. CST from April through September.
Attestation of Eligibility for an Enrollment Period
Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you.
By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
If none of these statements applies to you or you’re not sure, please contact Blue Advantage at 1-800-232-4967 (TTY users should call 711) to see if you are eligible to enroll. Our phone lines are open 7 days a week from 8 a.m. to 8 p.m.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.