Enrollment Forms
Once you've compared plans and premiums, you may decide you're ready to enroll. To do so, just download a copy of the appropriate enrollment form. For employer-sponsored application forms, contact your previous employer/union benefits administrator. There are certain dates when you can enroll in or switch to a new Medicare Advantage or Part D plan, so please be aware of these important dates.
2010 Enrollment Applications
- Medex Bronze and Medex Core application form and instructions
- Medicare HMO Blue PlusRx (HMO)
- Medicare PPO Blue PlusRx (PPO)
Blue MedicareRx*
(To access this form, you will be taken to the Blue MedicareRx website.)
2009 Enrollment Applications
- Medex Bronze and Medex Core application form and instructions
- Medicare HMO Blue application form
- Medicare PPO Blue application form
- Blue Medicare PFFS PlusRx application form (not available 1/1/2010)
Blue MedicareRx
(To access this form, you will be taken to the Blue MedicareRx website.)
Other Plan Forms
- Request for Medicare Advantage Prescription Drug Coverage Determination
- Medicare Part D Appointment of Representative Form
- Medicare Advantage Appointment of Representative Form
* Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare approved Part D Sponsor.
