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MedicareBlue PPO Enrollment Form

MedicareBlue Rx Enrollment Form

July 03, 2009

Important Information

This page last updated and accepted by CMS June, 2009.

MedicareBlue PPO is a regional Medicare Advantage Plan with a Medicare contract. MedicareBlue Rx is a regional Medicare Prescription Drug Plan with a Medicare contract. MedicareBlue PPO or MedicareBlue Rx coverage is separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.