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EnvisionRxPlus 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. Call EnvisionRxPlus Member Services at 1-866-250-2005 (TTY: 711), 24 hours a day, 7 days a week if you have questions about enrolling. By completing the form below you will be submitting an enrollment request to EnvisionInsurance.

  Your state:  

Please find additional information about this plan in the following links:

Enrollment Date
Election Type

Last Name: First Name: MI: Prefix:
Date of Birth Sex Home Phone: Cell Phone: Alternate Phone:
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
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)”, or “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 EnvisionRxPlus

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:
  Bank Account Holder Name:  
  Bank Routing Number:  
  Bank Account Number:  
  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 EnvisionRxPlus?
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 EnvisionRxPlus 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.
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:   Referral First Name: Referral Last Name:
Writing Code: Phone #:   Referral Code:  
Enrollment Terms & Conditions

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.

The referral 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.

Please Wait  


To complete the application, I will read to you several statements. When I have finished reading these statements, I will ask you if you understand and agree. You must understand and agree to these statements in order to complete your enrollment.

  • 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 EnvisionRxPlus, 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 EnvisionRxPlus could affect your employer or union health benefits. You could lose your employer or union health coverage if you join EnvisionRxPlus. 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 is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
  • EnvisionRxPlus is a Medicare drug plan and has a contract with the Federal government. This prescription drug coverage is in addition to your coverage under Medicare; therefore, you will need to keep your Medicare Part A or Part B coverage. It is your responsibility to inform EnvisionRxPlus of any prescription drug coverage that you have or may get in the future. You can only be in one Medicare prescription drug plan at a time – if you are currently in a Medicare Prescription Drug Plan, your enrollment in EnvisionRxPlus will end that enrollment.
  • I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with EnvisionRxPlus, he/she may be paid based on my enrollment in EnvisionRxPlus.
  • Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15- December 07), unless you qualify for special circumstances.
  • Once you are a member of EnvisionRxPlus, you have the right to appeal plan decisions about payment of services if you disagree. You agree to read the Evidence of Coverage document from EnvisionRxPlus when you get it to know which rules you must follow to get coverage with this Medicare drug plan.
  • If you leave the plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future.
  • Counseling services may be available in your 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.
  • By joining this Medicare prescription drug plan, you acknowledge that EnvisionRxPlus will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. EnvisionRxPlus will release your information, including your 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 your knowledge. If you intentionally provide false information, you will be disenrolled from the plan.
  • Your verbal acknowledgment at the end of this application process means that you understand the contents of this application. Additionally, if you are enrolling on behalf of another, you certify that you are authorized under State law to complete this enrollment, and documentation of this authority is available upon request by EnvisionRxPlus or by Medicare.
  • Please indicate by saying yes that you understand these statements and wish to enroll in the plan. We will be sending you acknowledgment of enrollment into our plan.

This concludes the enrollment application process. Your application will be submitted to Medicare for enrollment into (CSR repeat plan they enrolled beneficiary into).

Would you like me to send you any additional information?

Have I answered all of your questions today, or would you like formal follow-up?

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