Prescription Drug Enroll

Medicare Prescription Drug Enrollment Request

Welcome to the enrollment request page.

Before you enroll in a stand-alone Medicare Prescription Drug plan, make sure you understand all your options and how the plan you want to enroll works (including any deductibles, copays, coinsurance and out-of-pocket cost). Make sure you understand the Coverage Gap (also known as the Donut Hole). Unless you are enrolling in a Medicare Supplement, you can get better drug coverage with a Medicare Advantage Plan at no additional cost (you must continue to pay your Medicare Part B premium). If you still have questions, contact me or read about stand-alone Medicare Prescription Plan and/or about Medicare Advantage Plan.

I personally look at each enrollment request and will contact you for the steps necessary to complete the enrollment. Each company have their own procedures for enrollment. Once you submit the information, allow me between 24 and 48 business hours to response (does not include weekend and holidays). Feel free to also Contact me if you have questions.

Please Note: I am a licensed Agent in Colorado only. You must be a resident of Colorado to request an enrollment. However, I am looking into getting licenses in other states in the future. If you like what you see in my website and would like me to expand to your states, send me a request.

prescription drug plan ENROLLMENT

- Step 1 of 7

Are you a resident in the State of Colorado? *

Do you understand you are requesting enrollment in a plan and that a licensed sales agent will be contacting you to verify the information and to complete the enrollment? *

when do you want to start your plan? *

Plans always start on the first of the month and must be a future date.

With what company are you requesting an enrollment? *

Anthem Blue Cross and Blue Shield
Cigna-HealthSpring
Humana
SilverScript
AARP (UnitedHealthcare)
WellCare
Other
I am not sure. Please, contact me to find out what option is best for me.

Enter "Other" Company *

Do you know the Plan ID number for the plan you want to enroll? *

Yes
No - I will need assistance with the Plan ID

Plan ID *

Resident State *

SORRY, I CANNOT ENROLL YOU!!! You are not a resident of Colorado. I am only licensed in Colorado.

Enrollment understanding *

SORRY, ENROLLMENT IS NOT POSSIBLE!

Enrollment Information - You need to have an enrollment election period to enroll in a plan

Do you now have or are you waiting to receive your Medicare Part A AND/OR Medicare Part B soon? *

You must have at least one part (Part A OR Part B) to enroll in a Prescription Drug plan

No Medicare Part A or Part B *

You need at least one Medicare part (Medicare A OR Part B or Both) to qualify for enrollment in a Prescription Drug plan.

Are you new to Medicare? - Are you in your 7-months IEP (Initial Election Period)? (IEP starts 3 months before you meet eligibility requirements for Part B, includes the month of eligibility and ends 3 months after the month of eligibility) *

Are you enrolling during AEP (Annual Election Period) from October 15 until December 7? (Everyone can enroll during this period) *

Then, you must have a Special Election to be able to enroll. Click all that apply *

I recently lost or will terminate employer health insurance (including union or COBRA).
I recently moved permanently, will be moving or were disenrolled due to out-of-service-area
I have Medicaid and/or Extra Help for Prescription (LIS) (Can only use once per quarter)
I gained, lost or had a change in LIS/Extra Help status within the last 3 months.
I gained, lost or change Medicaid status in the last 3 months.
I dropped a Medicare Supplement plan and I am on a 12 months Medicare Advantage Trial Right.
I elected a Medicare Advantage when I first got Medicare but now, I want a Stand-Alone (and possibly a Medicare Supplement) before the end of my 12 months trial period.
I will like to enroll in a 5-star plan
I was auto enrolled by Medicare or State and want to change within the first 3 months.
I was affected by FEMA-declared emergency/disaster area.
I was recently released from incarceration.
I recently obtain lawful status in the United States of America.
I involuntarily lost creditable Prescription Drug coverage as good as Medicare.
I am moving, residing in or moving out of a Long-Term Care facility.
I have made a permanent move, notified of a move or were disenrolled due to out-of-service-area.
I recently disenrolled from the Program of All-inclusive Care for the Elderly (PACE).
I belong to a State Pharmaceutical Assistance Plan (SPAP) or lost SPAP eligibility.
I recently returned to the United States after living permanently outside of the U.S.
I am a New Medicare member and enrolled using my Initial Election Period (IEP) less than three months ago and want to change my plan.
None of the listed elections apply, however I have special circumstance to be allowed to enroll (Note: your application will pend).
Please, contact me to discuss my situation.

MEDICARE HEALTH INSURANCE CARD INFORMATION

NOTE: Enter the following information EXACTLY as it appears on your MEDICARE CARD

Name *

First

Middle

Last

MEDICARE NUMBER (MBI) *

Look at your Medicare card to find out what parts you have *

I only have Part A - Hospital
I only have Part B - Medical
I have both Part A and Part B

HOSPITAL (PART A) - Hospital start date (from your Medicare card) *

MEDICAL (PART B) - Medical start date (from your Medicare card) *

SEX *

Male
Female

Permanent Address - PO Box is not Allowed *

Address Line 1

Address Line 2

City

State

Zip Code

Select the county you reside *

Is Mailing Address different than Permanent Residence street address?

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Contact Information

Primary Phone *

Primary Phone Type *

Alternate Phone

Email *

Confirm Email

How would you like to receive all plans materials? *

USPS - United States Postal Service
Email

Date of Birth *

Preferred Language for Communication *

Enter "Other" Language for Communication - Other Language will be selected if it is available with the company. Otherwise, it will default to English. *

Preferred Material Format *

Who is requesting an enrollment? *

I am enrolling myself
I am an Authorized Representative, for example, Power Of Attorney (POA) enrolling a beneficiary. I will send the necessary documentation (Example, POA document) directly to the insurance company upon request.

Authorized Representative Name *

First

Last

Authorized Representative Address *

Address Line 1

Address Line 2

City

State

Zip Code

Authorized Representative Phone *

Are you enrolled in your state Medicaid Program? *

Medicaid ID Number *

Some individuals may have other drug coverage, including other private insurance, TRICARE, VA benefits, State Pharmaceutical Assistance Program or Federal Employee Health Benefits coverage. Will you have other prescription drug coverage in addition to the plan? *

This information helps determine if there is a need for coordination of benefits for prescription drugs.

Name of the Plan *

Member ID *

Group ID *

Effective Date *

Premium Payment Option *

Direct Pay (Get Monthly Statements or Coupon Book)
SSA (Automatic payment from Social Security check)
RRB (Automatic payment from Railroad Retirement Board)

You must select an option even for $0 premium plans.

Comment or Message

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