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2011 Prescription Blue PDPSM enrollment

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It's easy to enroll in our individual Prescription Blue PDPSM plans. Enroll now, or use the Prescription Blue PDPSM enrollment form to sign up for either of our two Prescription Blue PDPSM plans. Refer to Summary of Benefits for a description of each plan. For detailed benefit information, refer to Evidence of Coverage.

Download Enrollment Form below

Please select the form below. You will be presented with the enrollment form for Prescription Blue PDPSM. Fill out the form and be sure to make a copy of it to save for your records. Put the form in a stamped 9" x 11" envelope and return to us at:

Blue Cross Blue Shield of Michigan
Prescription Blue PDPSM Enrollment
P.O. Box 3667
Southfield, MI 48037-9928
Fax: 248-448-4041

Plan Enrollment Form
Prescription Blue PDPSM pre-enrollment booklet Pre-enrollment booklet (PDF 548K)
Prescription Blue PDPSM enrollment form Enrollment Form (PDF 178K)
Automatic deduction form Deduction Form (PDF 40K)

For more information contact Prescription Blue PDPSM at 1-877-469-2583 (TTY users call 1-800-481-8704) from 8 a.m. to 8 p.m. seven days a week.

Also, you can visit our Member Services Locations.

You may request the Prescription Blue PDPSM enrollment form in alternative formats by calling 1-877-469-2583 from 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704).

Medicare beneficiaries may enroll in Prescription Blue PDPSM through the Centers for Medicare and Medicaid Services Online Enrollment Center, located at www.medicare.gov.

Please remember:

To complete an Enrollment Form we sent you:

If you received an enrollment form in the mail from us, please fill it out completely. Be sure to check which plan you want to enroll in and to save a copy for your records. Put the completed enrollment form (do not fold it) in the 9" x 11" postage-paid envelope we sent you and mail it back to us. If you have not received this enrollment form, you can call us for one or download the appropriate enrollment form from this website.

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People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. 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 the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B. Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.

Medicare beneficiaries may enroll in Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. To learn more about enrollment periods, please contact Member Services.