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
For Blue Advantage Classic (HMO-POS), Blue Advantage Giveback (HMO-POS) and Blue Advantage Liberty (PPO): If we determine 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 mail, Electronic Funds Transfer (EFT), or credit/debit card each month, quarterly (pre-pay only), or annually (pre-pay only). You can also choose to pay your
premium by automatic deduction from your Social Security or Railroad Retirement Board Check each month.
For Blue Advantage Reliance (HMO-POS), Blue Advantage Platinum (HMO-POS) and Blue Advantage Premier (PPO): You can pay your monthly plan premium (including any late enrollment penalty you have or may
owe) by mail, Electronic Funds Transfer (EFT), or credit/debit card each month, quarterly (pre-pay only), or annually (pre-pay only). You can also choose to pay your premium by automatic deduction from your Social Security or
Railroad Retirement Board Check each month.
For Blue Advantage Dual Plus DSNP (HMO-POS): If your plan has a monthly premium or if we determine 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 mail, Electronic Funds Transfer (EFT), or credit/debit card each month, quarterly (pre-pay only), or annually (pre-pay only). You can also choose to pay your premium by
automatic deduction from your Social Security or Railroad Retirement Board Check each month.
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible,
Medicare could help pay for 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 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7
days per week. TTY/TDD users should call 1-877-486-2048.
If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of
your plan premium for this benefit. If Medicare pays only a portion of this premium, we will bill you for the amount
that Medicare does not cover.
If you don’t select a payment option, you will receive a bill each month.
(The Social Security or RRB deduction may take two or more months to begin after Social Security or RRB
approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction,
the first deduction from your Social Security or RRB benefit check will include all premiums due from your
enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your
request for automatic deduction, we will send you a paper bill for your monthly premiums.)
If you would like to pay your premium with Electronic Funds Transfer (EFT) or by Credit/ Debit card, please set up recurring payments once the application is submitted.
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.
Please contact Blue Advantage at 1-800-363-9152 (TTY users should call 711) if you need information in an accessible format or language other than what is listed above. Our office hours are 8 a.m. to 8 p.m., 7 days a week.
