Blue MedicareRx 2018 Change Form

A few quick tips about enrolling...

  • Please read this important information.
  • Make sure you meet the eligibility requirements.
  • Please review the Summary of Benefits, and Star Ratings.
  • You must complete each section before moving to the next one.
  • Your enrollment will not be saved until you click the Enroll Now button at the end of the application. If you click Exit Enrollment at any time (before clicking Enroll Now) and come back later, you will need to start over.
  • If you have problems enrolling online you can also:
    • Print and mail in the Blue MedicareRx paper enrollment form. If you need help with the form contact us.
    • Enroll by phone by calling 1-888-264-1568, 8 a.m. to 8 p.m., daily, local time. TTY hearing impaired users call 711. You have the option to speak with a licensed sales representative when you call this number.
  • If anyone helps you fill out your application, that individual must electronically sign the enrollment form and indicate his or her relationship to you.
  • No premium payment is required at the time you complete an enrollment application. If you complete a paper application, make a copy of your signed application for your records.

After you've enrolled & your enrollment is confirmed by Medicare

We’ll send you a letter confirming your enrollment and a member ID card. You’ll also receive a welcome kit that includes a member handbook, Evidence of Coverage (a full description of Blue MedicareRx benefits), and more.

Note: Do not disenroll from any other drug plan you may have until you receive confirmation of enrollment from Blue MedicareRx.