S5743_092419FF03_C
S5743_092419GFF05_C

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Complete this form only if you wish to change your MedicareBlue Rx (PDP) plan option. For premium or other changes, please call a Medicare Solutions specialist (see phone numbers below). To change to a different Medicare prescription drug plan option with MedicareBlue Rx, complete this form by checking the plan option you want and completing the form.

You may change your plan option during the annual enrollment period, from October 15 to December 7. Generally, you may not make changes at other times unless you meet certain special exceptions (see the Enrollment Period Determination section). For more information about enrollment periods please call a Medicare Solutions specialist.

If you select another plan option and we receive your completed form by the end of any month, your new benefit plan will generally begin the first of the following month. Selections made during the annual enrollment period (October 15-December 7) are effective January 1.

If you have any questions, please call a MedicareBlue Rx Solutions specialist at 1-866-434-2037, 8 a.m. to 8 p.m., daily, local time. TTY hearing impaired users call 711.

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