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Navitus (PDP)® for PRISM
Medicare Prescription Plan
Benefit Election Form
Effective Date: ____________________________
MEMBER ENROLLMENT OR CHANGE – COMPLETE IN FULL
Name (Last, First, MI): Social Security #: Birth Date (mm/
dd/yy): Male
Female
Home Street Address: (No P.O. Box) City, State, Zip Home Phone: Work Phone:
Mailing Address: (P.O. Box may be used) City, State, Zip
Same as Home Address
E-mail Address:
Occupation/Title: Date of Hire:
(mm/dd/yy):
Employee Status:
Medicare Retiree
Marital Status: Single Married Domestic Partner Legally Separated
Divorced
MEDICARE SECTION
Are you retired? Yes No If yes for Medicare for you and/or your dependent(s), please
provide your and/or their HICN/MBI number and indicate
the entitlement reason and Medicare eligibility date for
yourself and your dependents.
HICN/MBI Number: _______________________________
Entitlement Reason Over 65 Disabled ESRD
Effective Date of Medicare: ________________________
If yes, what
Medicare are YOU
enrolled in?
Part A
Part B
Is your dependent
(s) enrolled in
Medicare?
Yes No Name: __________________________________________
2
If Yes for
dependent, what
Medicare are they
enrolled in?
Part A
Part B
HICN Number: ____________________________________
Date of Birth: _____________________________________
Gender: _________________________________________
Relationship: _____________________________________
Entitlement Reason: Over 65 Disabled ESRD
Effective Date of Medicare: ________________________
Enroll In Employer Group Waiver Program (Navitus Medicare PDP)
Retiree Spouse
PLEASE READ THE FOLLOWING- AUTHORIZATION REQUIRED
I declare that the information given on this form is true and complete to the best of my
knowledge and belief. I understand that the information I have provided is the basis on which
coverage may be issued under these plans. Any misstatements or omissions may result in
future claims being denied and/or my coverage(s) being rescinded. I know that if I do not enroll
within 30 days of becoming first eligible (or within 31 days of an IRS-qualified change in status) I
will have to wait until the next annual enrollment, and may be required to submit evidence of
insurability for certain coverage.
Signature:Date:
DECLINATION OF COVERAGE – SIGNATURE REQUIRED- Complete only if declining EGWP Rx
coverage
I understand that I am eligible for medical and Rx coverage through my employer. I waive the right to enroll in
the medical plan and Rx plan as offered to me by my employer for the following reason (please check one):
I am covered under another Medicare Advantage/Supplement
Plan I am covered through my spouse’s employer
I have no other coverage but choose not to enroll
I understand that by declining coverage, I will not be eligible for coverage until my employer’s next Open
Enrollment period unless I qualify for coverage due to a HIPAA qualifying event (including getting married,
having a child, or involuntarily losing my other coverage). Please contact the Benefits Office at the
organization from which you retired for retiree plan provisions.
Signature:Date: