Thank you for choosing a Medicare plan from Priority Health Medicare!

If you are already a member of a Priority Health Medicare plan and would like to change to a different Priority Health Medicare plan, please call us at toll-free 888 389-6676, from 8:30 a.m. to 5:00 p.m., Monday – Friday. TTY/TDD users should call toll free 888 551-6761.

Before we get started, check to be sure you are eligible.

• You are enrolling as an individual and not in a Medicare plan through your employer.
• You must live in a Michigan County where Priority Health Medicare offers the plan you select.
• You must be entitled to Medicare Part A and enrolled in Medicare Part B, and continue to pay your Medicare Part B premiums.
• Typically, you may enroll in a Medicare plan only during specific times of the year. For more information about these enrollment periods call our Priority Health Medicare representatives at toll-free 888 389-6676, from 8:30 a.m. to 5:00 p.m., Monday – Friday. TTY/TDD users should call 888 551-6761.

Have your red, white and blue Medicare card or letter from the Social Security Administration concerning your entitlement handy. You’ll need information from it to fill out this enrollment form.

Enrolling online is safe and secure.

We secure all information you enter, so only you and Priority Health Medicare will be able to view it. By filling out this form, you’ll be officially enrolling in a Priority Health Medicare plan.

You can always call us with questions.

Our Priority Health Medicare representatives are available to answer your questions or help you enroll over the phone from 8:30 a.m. to 5:00 p.m., Monday – Friday. Call toll-free 888 389-6676, TTY/TDD users should call 888 551-6761.

If you prefer you can print and mail in your enrollment form.
Priority Health Medicare Advantage plan enrollment form (153KB PDF).

Enrollment checklist

Typically, you may enroll in a Medicare Advantage plan during the annual enrollment period between November 15 and December 31 of each year. In addition, you can join a Medicare Advantage plan during the open enrollment period between January 1 and March 31 of each year, as long as you don’t add or drop your prescription drug coverage (i.e. if you have Medicare prescription drug coverage you can only change to another plan with Medicare prescription drug coverage; if you don’t have Medicare prescription drug coverage you can only change to another plan without Medicare prescription drug coverage). Additionally, there are exceptions that may allow you to enroll in a Medicare Advantage plan outside of these periods.

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 in incorrect, you may disenrolled.

I am new to Medicare.

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me. I moved on (insert date):

I recently retired. I retired on:

I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.

I get extra help paying for Medicare prescription drug coverage.

I no longer qualify for extra help paying for my Medicare prescription drugs. I stopped receiving extra help on (insert date):

I am moving into, live in, or recently moved out of a Long Term Care Facility (for example, a nursing home). I moved/will move into/out of the facility on (insert date):

I recently left a PACE program. I left on (insert date):

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare). I lost my coverage on (insert date):

I am leaving employer or union coverage. I am leaving on (insert date):

I belong to a pharmacy assistance program provided by my state.

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date):

None of these statements applies to me.

If none of these apply to you, please contact Priority Health Medicare toll-free at 888 389-6648 to see if you are eligible to enroll. TTY/TDD users should call toll-free 888 551-6761. We are open 7 days a week from 8:00 a.m. - 9:00 p.m.

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Choose which plan you want to enroll in:

PriorityMedicare Value
PriorityMedicare
PriorityMedicare Plus
PriorityMedicare Choice

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Personal information

Title
Mr. Mrs. Ms.

First name:


Middle initial:


Last name:


Birth date:


Gender:
Male Female

Home phone number:


E-mail address:

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Permanent residence

Please enter your permanent address below. If you have more than one residence, enter your primary residence.

Address (line 1):


Address (line 2):


City:


County:


State:


ZIP code:

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Mailing address (optional):

Please provide the address where you would like to receive correspondence. If this is the same as your permanent address, leave this section blank.

Mailing address (line 1):
Only provide if different from your permanent residence address


Mailing address (line 2):


City:


State:


ZIP code:

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Your Medicare insurance information

Please take out your Medicare card to complete this section. In the spaces provided, enter your Medicare Claim Number and the Effective Dates of your Part A and Part B coverage. You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Name:


Medicare claim number:


Entitled to: Hospital (Part A)


Entitled to: Medical (Part B)

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Paying your plan premium

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 coinsurance. 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 http://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.

If we determine that you owe a late enrollment penalty, we need to know how you would prefer to pay it. You can pay your late enrollment penalty and/or monthly plan premium by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security benefit check each month.

Select premium payment option :
Electronic funds transfer (EFT) from your bank account each month.
Please mail a VOIDED check to Priority Health Enrollment, MS 1175, 1231 East Beltline, Grand Rapids, MI, 49525.

Receive a bill monthly and pay the plan directly by mail.

Automatic deduction from your Social Security benefit check. Note: This deduction may take two or more months to begin. In most cases, the first deduction from your Social Security benefit check will include all premiums due from your enrollment effective date up to the point withholding begins.

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Additional questions

Do you have end stage renal disease (ESRD)?
Yes No

If you answer "yes" to this question and you do not need regular dialysis any more, or if you have had a successful kidney transplant, we will ask you for a note or records from your doctor showing you do not need dialysis or have had a successful kidney transplant.

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Some individuals may have additional prescription drug coverage, including other private insurance, TRICARE, federal employee health benefits, VA benefits, or state pharmaceutical assistance programs.

Will you have additional prescription drug coverage?
Yes No
If you answered "yes", please provide the following information.

Name of additional coverage:


ID number for this coverage:


Group number for this coverage:

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Are you a resident in a long-term care facility, such as a nursing home?
Yes No

If you answered "yes", please provide the following information.

Name of facility:


Address:


City:


State:


ZIP code:


Phone number:

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Are you enrolled in your State Medicaid program?
Yes No

If yes, enter your Medicaid number:

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Do you or your spouse work?
Yes No

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If you prefer us to send you information in another format or language (like Baille or large print), please contact Priority Health Medicare toll free 888 389-6676 (TTY/TDD users should call toll-free 888 551-6761), 24 hours a day, 7 days a week.

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Your primary care physician (PCP)

Enter the name of a primary care physician (PCP), clinic, or health center unless you are enrolling in PriorityMedicare Choice:

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Agreement

If you currently have health coverage from an employer or union, joining a Priority Health Medicare Advantage plan could affect your employer or union health benefits. If you have health coverage from an employer or union, joining a Priority Health Medicare Advantage plan may change how your current coverage works. 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 is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing and submitting this enrollment form, I agree to the following:
Priority Health Medicare plans are Medicare Advantage plans and have a contract with the federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: November 15-December 31 of every year), or under certain special circumstances. Priority Health Medicare serves a specific service area. If I move out of the area that Priority Health Medicare serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Priority Health Medicare, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage from Priority Health Medicare when I get it to know which rules I must follow in to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border. I understand that beginning on the date PriorityMedicare Value (HMOPOS), PriorityMedicare (HMOPOS), or PriorityMedicare Plus (HMOPOS) coverage begins, I must get all of my health care from Priority Health Medicare, except for emergency or urgently needed services or out-of-area dialysis services. I understand that beginning on the date PriorityMedicare Choice (PPO) coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, Priority Health Medicare provides refunds for all covered benefits, even if I get services out of network. Services authorized by Priority Health Medicare and other services contained in my Priority Health Medicare Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Priority Health Medicare WILL PAY FOR THE SERVICES. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Priority Health Medicare, he/she may be paid based on my enrollment in Priority Health Medicare. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program. Release of Information: By joining this Medicare health plan, I acknowledge that Priority Health Medicare will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Priority Health Medicare will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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.

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E-Signature

I understand that in completing this form, I (or the person authorized to act on behalf of the individual under the laws of the State where the individual resides) have read and understand the contents of the application. If completed by an authorized individual (as describe above), submission of this form certifies that: 1) this person is authorized under the State law to complete this enrollment and 2) documentation of this authority is available upon request by Priority Health Medicare or by Medicare.

E-Signature
I understand and wish to complete enrollment in this Priority Health Medicare Advantage plan
I don't wish to complete enrollment

If you are the authorized representative, you must provide the following information.

Name of authorized representative:


Address:


City:


State:


ZIP code:


Phone number:


Relationship to enrollee:


If you are an agent, please provide the following information.

Referring agent:


Referring agent number :

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Office use only

Name of staff member (if assisted in enrollment):


Subscriber ID:


PBP ID:


Effective date of coverage:


Eligible as:
ICEP/IEP
OEP
AEP
SEP
Not eligible

Print

WARNING: Print this form now.
You will not be able to print it after you click "Enroll."