Blue Cross MedicareRxMedicare Prescription Drug Plan Individual Enrollment Form Blue Cross MedicareR 2026

1. Click ‘Get Form’ to open the Blue Cross MedicareRx Individual Enrollment Form in our editor.
2. Begin by selecting the plan you wish to enroll in: Basic, Value, or Plus. Fill in your last name, first name, middle initial, and sex.
3. Enter your birth date, home phone number, and alternate phone number. Provide your permanent residence address (P.O. Box is not allowed) including city, state, and ZIP code.
4. If applicable, fill out your mailing address if it differs from your permanent residence. Next, provide emergency contact details including their name and relationship to you.
5. Complete the Medicare insurance information section by entering your name as it appears on your Medicare card along with your Medicare number.
6. Review the attestation of eligibility section carefully and check any boxes that apply to you regarding enrollment periods.
7. Select a payment option for your plan premium: bill by mail, electronic funds transfer (EFT), or automatic deduction from Social Security benefits.
8. Answer questions about existing drug coverage and long-term care facility residency as required.
9. Finally, read the important information section thoroughly before signing and dating the application at the bottom of the form.

Start filling out your Blue Cross MedicareRx enrollment form online for free using our platform today!