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.
• You must be entitled to Medicare Part A and/or enrolled in Medicare Part B and if enrolled in Part B, 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 PriorityMedicare Rx.

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.
PriorityMedicare Rx plan enrollment form (155KB PDF).

Enrollment checklist

Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period between November 15 and December 31 of each year. Additionally, there are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the annual enrollment 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 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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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/or Part B coverage. You must have Medicare Part A or Part B (or both) 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.

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

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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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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Agreement

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining [PriorityMedicare Rx], your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan.

If you currently have health coverage from an employer or union, joining PriorityMedicare Rx could affect your employer or union health benefits. You could lose your employer or union health coverage if you join PriorityMedicare Rx. 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 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:
PriorityMedicare Rx is a Medicare drug plan and has a contract with the federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform PriorityMedicare Rx of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time – if I am currently in a Medicare Prescription Drug Plan, my enrollment in PriorityMedicare Rx will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (November 15 – December 31), unless I qualify for certain special circumstances. PriorityMedicare Rx serves a specific service area. If I move out of the area that PriorityMedicare Rx serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use PriorityMedicare Rx network pharmacies. Once I am a member of PriorityMedicare Rx, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from PriorityMedicare Rx when I get it to know which rules I must follow to get coverage. I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with PriorityMedicare Rx, he/she may be paid based on my enrollment in PriorityMedicare Rx. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program. Release of Information: By joining this Medicare prescription drug plan, I acknowledge that PriorityMedicare Rx will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that PriorityMedicare Rx will release my information, including my prescription drug event date, 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 my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 PriorityMedicare Rx or by Medicare.

E-Signature
I understand and wish to complete enrollment in this PriorityMedicare Rx
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

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