Plan Selection Change Form

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 following month.

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.


 Receive a bill
 Automatic deduction from your monthly Social Security (SSA) benefit check
 Automatic deduction from your monthly Railroad Retirement Board (RRB) benefit check
 Electronic funds transfer (EFT) from your bank account each month

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, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
American Indian or Alaska Native
Asian Indian
Black or African American
Chinese
Filipino
Guamanian or Chamorro
Japanese
Korean
Native Hawaiian
Other Asian
Other Pacific Islander
Samoan
Vietnamese
White
Other
I choose not to answer.

Plan Documents


 Spanish
 Audio CD
 Braille
 Digital Documents (only certain documents are available in a paperless format)
 Large Print

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.

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Blue Advantage (HMO) or Blue Advantage (PPO).
  • By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Blue Advantage (HMO) or Blue Advantage (PPO) 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 when my Blue Advantage (HMO) or Blue Advantage (PPO) coverage begins, I must get all of my medical and prescription drug benefits from Blue Advantage (HMO) or Blue Advantage (PPO). Benefits and services provided by Blue Advantage (HMO) or Blue Advantage (PPO) and contained in my Blue Advantage (HMO) or Blue Advantage (PPO) “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Blue Advantage (HMO) or Blue Advantage (PPO) will pay for benefits or services that are not covered.
  • 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.

 I am an Authorized Personal Representative

If you are the Authorized Personal Representative, you must provide the following information: