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Call Us: 1-866-250-2005 (TTY/TDD 711)
EnvisionRx Plus Enrollment Request

The Annual Election Period is from October 15 through December 7 of each year. During this time anyone eligible for Medicare Part D may enroll with us. You may also enroll with us throughout the year if this is your Initial Enrollment Period (first time you are eligible for Medicare Part D) or if you qualify for the Special Enrollment Period. Please call EnvisionRx Plus Member Services at 1-866-250-2005 (TTY/TDD users should call 711), 24 hours a day, 7 days a week to find out if you can enroll today!

You have chosen to enroll in our following plan: EnvisionRx Plus Silver Plan

Complete the form below to enroll in EnvisionRx Plus. By completing and submitting this form, you understand that you are sending an actual enrollment request to EnvisionRx Plus.

Last Name: First Name: MI: Prefix:
Date of Birth Sex Home Phone Number:
Permanent Residence Address Line 1: (P.O Box Not Allowed) Address Line 2:
City: State: Zip Code:
Mailing Address Line 1
(only if different from your Permanent Address):
Address Line 2:
City: State: Zip Code:
Emergency Contact: Phone #: Relationship:
Email Address:
Please Provide Your Medicare Insurance Information:
Please take out your Medicare Card to complete this section.
  • Please fill in these blanks so they match your red, white and blue Medicare card
  • - OR -
  • Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.
You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan.
Medicare Health Insurance Logo
Medicare Claim Number: Sex:
Is Entitled to: Effective Date:
Paying Your Plan Premium:
You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail “Electronic Funds Transfer (EFT)”, “credit card” each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or Railroad Retirement Board benefit check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to EnvisionRx Plus

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will receive a bill each month.

Please select a premium payment option:
  Checking Account Holder Name:  
  Bank Routing Number:  
  Bank Account Number:    * Checking Account Only
  Type of Card:  
  Name of Account Holder:     * As it Appears on Card
  Account Number:  
  Expiration Date:    / 
Please Answer the Following Questions to Help Medicare Coordinate Your Benefits:
1. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to EnvisionRx Plus?
If "yes", please list your other coverage and your identification (ID) number(s) for this coverage:
Coverage Name: Coverage ID: Coverage Group#:
2. Are you a resident in a long-term care facility, such as a nursing home?
If "yes", please provide the following information:
Institution Name:
Institution Address Line 1: Institution Address Line 2:
City: State: Zip Code: Phone #:  
Please check one of the boxes below if you would prefer that we send you information in a language other than English or in another format:
Please contact EnvisionRx Plus at 1-866-250-2005 if you need information in another format or language than what is listed above. TTY users should call 711. Our office hours are 24 hours a day, 7 days a week.
Please Read This Important Information:

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining EnvisionRx Plus, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan.

If you currently have health coverage from an employer or union, joining EnvisionRx Plus could affect your employer or union health benefits. You could lose your employer or union health coverage if you join EnvisionRx Plus. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Accept Below:

By completing this enrollment application, I agree to the following:

EnvisionRx Plus is a Medicare drug plan and has a contract with the Federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform EnvisionRx Plus of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time - if I am currently in a Medicare Prescription Drug Plan, my enrollment in EnvisionRx Plus will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15- December 7 ), unless I qualify for certain special circumstances.

EnvisionRx Plus serves a specific service area. If I move out of the area that EnvisionRx Plus serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use EnvisionRx Plus network pharmacies. Once I am a member of EnvisionRx Plus, I have the right to appeal plan decisions about payment of services if I disagree. I will read the Evidence of Coverage document from EnvisionRx Plus when I get it to know which rules I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with EnvisionRx Plus, he/she may be paid based on my enrollment in EnvisionRx Plus.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program, and the Medicare Savings Program.

Release of Information:

By joining this Medicare prescription drug plan, I acknowledge that EnvisionRx Plus will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that EnvisionRx Plus will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by EnvisionRx Plus or by Medicare.

Are you the enrollee?   Enrollee Representative  
If "no", please provide the following information:
Name: Address Line 1: Address Line 2:
City: State: Zip Code: Phone #: Relationship:
------------------------------------ For Broker Use Only ---------------------------------
First Name: Last Name:  
Writing Code: Phone #:

The broker information you entered does not match our records. Please verify or re-enter the information and submit again. If the problem persists, please contact us at envisionagentsupport@envisionrx.com. We will respond 8:00am - 5:00pm PST. This application may also be submitted by fax to 1-844-293-4756.

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