Prescription Advantage Application Form 2025

1. Click ‘Get Form’ to open the Prescription Advantage Application Form in our editor.
2. Begin by filling out Section A, which includes Applicant and Spouse Information. Indicate if someone else is completing the form on behalf of the applicant and provide their name and relationship.
3. Continue by specifying who is applying—either just you or you and your spouse. If both are applying, indicate if you want to be designees for each other.
4. Complete the personal details for both the applicant and spouse, including names, Social Security numbers (optional), Medicare enrollment status, date of birth, preferred language, and gender.
5. In Section B, provide your residence and contact information. Ensure that all addresses are accurate and include a valid telephone number.
6. Proceed to Section C to disclose household information regarding relatives living with you who depend on financial support.
7. Fill out Sections D through G regarding other prescription drug coverage, Extra Help from Medicare, employment status, disability information, and income verification as required.
8. Finally, review all sections for accuracy before signing at the end of the form. Both the applicant and spouse must sign if applicable.

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