It's easy to enroll in our individual Prescription Blue PDPSM plans. Contact us to enroll, or use the Prescription Blue PDPSM enrollment form to sign up for either of our two Prescription Blue PDPSM plans. Refer to Summary of Benefits for a description of each plan. For detailed benefit information, refer to Evidence of Coverage.
Download Enrollment Form Below
Please select the form below. You will be presented with the enrollment form for Prescription Blue PDPSM. Fill out the form and be sure to make a copy of it to save for your records. Put the form in a stamped 9" x 11" envelope and return to us at:
Blue Cross Blue Shield of Michigan Prescription Blue PDPSM Enrollment
P.O. Box 3667
Southfield, MI 48037-9928
Fax: 248-448-4041
You may request the Prescription Blue PDPSM enrollment form in alternative formats by calling 1-877-469-2583 from 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704).
Medicare beneficiaries may enroll in Prescription Blue PDPSM through the Centers for Medicare and Medicaid Services Online Enrollment Center, located at medicare.gov.
Please remember:
Do not send us your enrollment form until November 15, 2009.
You will need one form for each person enrolling in a plan.
You can only enroll in one plan.
Do not enclose payment with your enrollment form. We'll bill you or, if you requested it through use of the automatic deduction form, above, we'll automatically deduct your premium from your bank account. Social Security deductions can also be arranged after you have received a member ID card.
If you currently have Medicare supplemental and/or prescription drug coverage from an employer group or union and are considering enrolling in Prescription Blue PDPSM, call your group benefits representative first to determine if you need this coverage.
To Complete an Enrollment Form We Sent You:
If you received an enrollment form in the mail from us, please fill it out completely. Be sure to check which plan you want to enroll in and to save a copy for your records. Put the completed enrollment form (do not fold it) in the 9" x 11" postage-paid envelope we sent you and mail it back to us. If you have not received this enrollment form, you can call us for one or download the appropriate enrollment form from this Web site.
Prescription Blue is a prescription drug plan with a Medicare contract and is available to all Medicare beneficiaries who are Michigan residents entitled to Part A of Medicare or enrolled in Part B.
Prescription Blue is issued by Blue Cross Blue Shield of Michigan, a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Prescription Blue's contract with CMS is renewed annually and the availability of coverage beyond the end of the current contract year is not guaranteed.
The person that is discussing plan options with you is either employed by or contracted with Blue Cross Blue Shield of Michigan (BCBSM). The person may be compensated based on your enrollment in a plan.
Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.
Prescription Blue PDPSM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B. Premiums vary by county. You must continue to pay your Medicare Part B premium.
Medicare beneficiaries enrolled in a Medicare Advantage PFFS plan that includes Medicare prescription drugs or any Medicare Advantage coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or Medicare Advantage PFFS plan if they enroll in a prescription drug plan; and Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, a Medicare Advantage Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a prescription drug plan and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.
In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Prescription Blue PDPSM. For additional information on network pharmacies, please call Customer Service at 1-877-469-2583, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704. You may also write to: Prescription Blue PDPSM, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.
If you decide to have your Prescription Blue PDPSM premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.
Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Prescription Blue PDPSM for details.
In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Prescription Blue PDPSM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, please contact Prescription Blue PDPSM at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may only enroll in Prescription Blue PDPSM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.
This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
Prescription Blue PDPSM is issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Prescription Blue PDP'sSM contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
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