FB – Enrollment Checklist Beneficiary EN

Enrollment Checklist - Applicant’s

Applicant’s Last Name:

Applicant’s First Name:

Florida Blue is required by Medicare to contact you within 15 days of receiving your enrollment application. Within the next 15 days you will receive a letter from Florida Blue to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. This will not affect your ability to enroll in the plan.
Your sales agent will review the following questions with you to verify that the Medicare Advantage or Part D Prescription Drug plan was fully explained. Check Yes or No as appropriate.

For Medicare Advantage plans:

YESNO	Do you understand that you have applied for a Medicare Advantage plan? This plan is not a Medicare Supplement “Medigap” plan. This plan replaces Original Medicare.
YESNO	Do you understand that to enroll you must be “entitled” to Part A and enrolled in Part B?
YESNO	Do you understand you must continue to pay your Medicare Part B premium (unless it is paid for you by Medicaid or another third party)?

For Part D Prescription Drug plans

YESNO	Did the sales agent fully explain the prescription deductible associated with the plan (if applicable), and the amount?
YESNO	Do you understand you have applied for a Part D Prescription Drug plan?
YESNO	Do you understand to enroll you must have Medicare Part A and/or Part B?

For All plans:

YESNO	Did the sales agent fully explain your premium, benefits, copays, and coinsurance amounts?
YESNO	Did the sales agent show you the Summary of Benefits and give you a copy?
YESNO	Did the sales agent give you their contact information? (name, phone or business card)
YESNO	Did the sales agent explain the plan’s drug list (also referred to as a formulary) and drug tiers?
YESNO	Did the sales agent explain the coverage gap, sometimes referred to as the doughnut hole?
YESNO	Do you understand that in most cases you must use a pharmacy in our drug plan network?
YESNO	Did the sales agent confirm that your prescription drugs are covered under the plan’s drug list?
YESNO	Do you understand if you enroll in a Medicare Advantage plan and later decide to make a change, under most circumstances you are able to do so during the Annual Enrollment Period, October 15 -December 7 each year?

Drug Information

Drug Name	Covered	Tier	Cost	B vs. D*	PA	Qty Limits	Step Therapy

*Some drugs may be covered under Medicare Part B or Part D. To determine coverage under the appropriate Medicare benefit, your doctor is required to submit a Medicare Part B vs. D coverage determination form to Florida Blue to obtain prior approval for these medications before the prescription is filled.

Only for HMO & PPO plans

YESNO	Did the sales agent fully explain the medical deductible associated with the plan, (if applicable), and the amount?
YESNO	Do you understand that you must use in-network health care providers to get the in-network benefits, copays and coinsurances?
YESNO	Do you understand that if you use out-of-network health care providers you will likely pay higher out-ofpocket costs? (Note: HMO members are not covered out-of-network, except in emergencies, urgent care and out-of-area dialysis.)
YESNO	Did the sales agent confirm that your doctor(s) is(are) in-network for the plan that you selected?

Provider information

Provider’s Name	Par/Non-Par	Provider’s Complete Address

Acknowledgement

My agent and I have reviewed all my doctor(s), hospital(s) and prescription drug(s) that I have provided today. We have discussed each provider’s participating status within my plan as well as my cost share and any requirements or limits regarding my prescription drug(s). I understand that some network providers may be added or removed from the network at any time. For any additional providers or to get the most up-to-date information about my plan’s network providers for my area or my prescription drugs, I will visit floridablue.com/medicare or call the Member Services Department at 1-800-926-6565, 8 a.m. – 8 p.m. local time, seven days a week from October 1 - March 31, except for Thanksgiving and Christmas. From April 1 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. (TTY users should call 1-800-955-8770.)

Applicant’s Signature:

Agent’s Signature:

This information is available for free in other languages. Please call our Customer Service number at 1-855-601-9465. (TTY users should call 1-800-955-8770.) Hours are 8 a.m. - 8 p.m. local time, seven days a week from October 1 to March 31, except for Thanksgiving and Christmas. From April 1 to September 30, we are open Monday - Friday, 8 a.m. - 8 p.m., local time.

Esta información está disponible de manera gratuita en otros idiomas. Comuníquese con Atención al cliente al 1-855-601-9465. ( Usuarios de equipo telescritor TTY llamen al 1-800-955-8773.) Estamos abiertos de 8 a.m. a 8 p.m. hora local los siete días de la semana, desde el 1 de octubre hasta el 31 de marzo, excepto el día de Acción de Gracias (Thanksgiving) y el día de Navidad. Desde el 1 de abril al 30 de septiembre, estamos abiertos de lunes a viernes de 8:00 a.m. a 8:00 p.m. hora local.

Florida Blue is a PPO, RPPO and Rx (PDP) Plan with a Medicare contract. Florida Blue Medicare is an HMO Plan with a Medicare contract. Enrollment in Florida Blue or Florida Blue Medicare depends on contract renewal.

Health coverage is offered by Blue Cross and Blue Shield of Florida, D/B/A Florida Blue. HMO coverage is offered by Florida Blue Medicare, Inc., an HMO affiliate of Florida Blue. These companies are independent licensees of the Blue Cross and Blue Shield Association.

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