) Individual Enrollment form · Plan (PDP) Individual Enrollment form PO Box 1827 Medford, OR 97501 1-844-ASURIS2 (1-844-278-7472) Fax number 1-888-335-2988 TTY 711 Please contact

Asuris Medicare Prescription Drug Plan (PDP) Individual Enrollment form

PO Box 1827 Medford, OR 97501 1-844-ASURIS2 (1-844-278-7472) Fax number 1-888-335-2988 TTY 711

Please contact Asuris Prescription Drug Plans if you need information in another language or format.

To enroll in an Asuris Prescription Drug Plan, please provide the following information:

Please check which plan you want to enroll in: Asuris Medicare ScriptTM Saver (PDP) $38.00 Asuris Medicare ScriptTM Basic (PDP) $91.00 Asuris Medicare ScriptTM Enhanced (PDP) $120.00

Please print clearly LAST Name: FIRST Name: Middle Initial: Mr.

Mrs. Ms.

Birthdate: (mm/dd/yyyy) Sex: M F

Home Phone Number: Alternate Phone Number (Cell Phone):

I consent to be contacted at the telephone number I have provided above from or on behalf of Asuris, healthcare providers, or their respective agents. These calls or texts may be about treatment options, other health-related benefits and services, enrollment, payment or billing. Permanent Residence Street Address (P.O. Box is not allowed):

City: State: ZIP Code: County:

Mailing Address (only if different from your Permanent Residence Address): Street Address:

City: State: ZIP Code: County:

E-mail address:

By providing your email, you give permission to be contacted about future Medicare news and plan information via email. You may opt out of email communication at any time. Emergency Contact: Phone Number: Relationship to You:

Y0062_4437_2020 CH03 EX01-01A_C 1 of 6 FORM 4437AS (Eff. 10/19) v2 *F4437.XAS0EN10190106* *F4437.XAS0EN10190106*

Paying Your Plan Premium You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail, online, by phone or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security or Railroad Retirement Board benefit check or be billed directly by Medicare. Do NOT pay the Part D-IRMAA extra amount to Asuris Prescription Drug Plans. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover. If you don’t select a payment option, you will receive a bill each month. Please select a premium payment option: Receive a bill (A billing statement will be sent in the mail) Electronic funds transfer (EFT) from your bank account each month. Please enclose a preprinted

VOIDED check or provide the following:

Account Holder Name: _________________________________________________________ If Account Holder name is NOT the name of the applicant on this application, please sign below to authorize deductions: ___________________________________________

(Signature of Account Holder)

Bank Routing Number: __________________ Bank Account Number: __________________ Account type: Checking Savings

Please Provide Your Medicare Insurance Information Please take out your red, white and blue Medicare card to complete this section.

Fill out this information as it appears on your Medicare card.

- OR - Attach a copy of your Medicare card or your

letter from Social Security or the Railroad Retirement Board.

Name (as it appears on your Medicare card): _______________________________________ Medicare Number: _______________________________________ Is Entitled To: Effective Date:

HOSPITAL (Part A) ___________________

MEDICAL (Part B) ___________________ You must have Medicare Part A or Part B (or both) to join a Medicare prescription drug plan.


Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check. I get monthly benefits from: Social Security RRB (The Social Security/Railroad Retirement Board deduction may take two or more months to begin. In most cases, if Social Security/the Railroad Retirement Board accepts your request for automatic deduction, the first deduction from your Social Security/Railroad Retirement Board benefit check will include all premium due from your enrollment effective date up to the point withholding begins. If the first deduction does not include all premiums, you will be responsible for paying your premiums directly to the plan until Social Security or RRB deductions start. If Social Security/the Railroad Retirement Board does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Additional Payment options available: • Pay online - This is the fastest and easiest way to pay. Plus, it’s safe and convenient. Just go to

asuris.com/paying-premiums

• Pay by phone - Call our automated payment system at 1 (888) 431-2063. Have your banking information and member ID number ready.

Please answer the following question: Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

1. Will you have other prescription drug coverage in addition to this Asuris Prescription Drug Plan? Yes No If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage: _________________________________________ ID # for this coverage: ______________________________________

Group # for this coverage: ___________________________________

RX Bin #: _____________________ PCN Number: _____________________

2. Are you a resident in a long-term care facility, such as a nursing home? Yes No If “yes,” please provide the following information:

Name of Institution: ____________________________________________________________ Address & Phone Number of Institution (number and street): ____________________________ ____________________________________________________________________________

Please check one of the boxes below if you would prefer that we send you information in a language other than English or in an accessible format: Please check this box if you’d like to be contacted concerning any other available formats Please check this box if you’d like to be contacted concerning any other available languages Please contact Asuris Prescription Drug Plans at 1 (800) 541-8981 if you need information in an accessible format or language other than what is listed above. Our office hours are from 8 a.m. to 8 p.m., Monday through Friday. From October 1 through March 31, our office hours are 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. Live online chat assistance is also available from 8 a.m. to 5 p.m. Monday through Friday. To access online chat log in at asuris.com/Medicare and click the Contact Us link. Evidence of Coverage, Drug List (formulary), and Provider Directories are provided in electronic version available online at asuris.com/medicare. To request print versions, contact Customer Service.


___________

STOP Please read this important information

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining an Asuris Prescription Drug Plan, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have questions, contact your Medicare Advantage Plan. If you currently have health coverage from an employer or union, joining an Asuris Prescription Drug Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join an Asuris Prescription Drug Plan. Read the communications your employer or union sends you. If you have questions, visit their Website, or contact the office listed in their communications. If there isn’t information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Typically, you may enroll in a Medicare Prescription Drug Plan only during the annual enrollment period from October 15 through December 7 of each year. Additionally, there are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the annual enrollment period. Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled. Annual Enrollment Period I am new to Medicare. (Enrollment election period is up to 3 months prior to Medicare A & B

entitlement dates). I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare

Advantage Open Enrollment Period (MA OEP) between January 1st and March 31st. I recently moved outside of the service area for my current plan or I recently moved and this

plan is a new option for me. I moved on (insert date) ___________ I recently was released from incarceration. I was released on (insert date) ___________ I recently returned to the United States after living permanently outside of the U.S. I returned to

the U.S. on (insert date) ___________ I recently obtained lawful presence status in the United States. I got this status on (insert date)

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on (insert date) ___________,

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in level of Extra Help, or lost Extra Help) on (insert date) ___________.

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

I live in or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date) ___________

I recently left a PACE program on (insert date) ___________

Continued on next page


___________

I recently involuntarily lost my creditable prescription drug coverage (as good as Medicare’s). I lost my drug coverage on (insert date) ___________

I am leaving employer or union coverage on (insert date) ___________ I ended my enrollment in a Medicare Advantage Plan with a valid election reason (insert date)

I belong to a pharmacy assistance program provided by my state. My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My

enrollment in that plan started on (insert date) ___________. I was affected by a weather-related emergency or major disaster (as declared by the Federal

Emergency Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact Asuris Prescription Drug Plans at 1-800-541-8981 to see if you are eligible to enroll. We are open from 8 a.m. to 8 p.m., Monday through Friday. From October 1 through March 31, our telephone hours are 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. Live online chat assistance is also available from 8 a.m. to 5 p.m. Monday through Friday. To access online chat log in at asuris.com/medicare and click the Contact Us link.

Please read and sign below (Signature on next page) By completing this enrollment application, I agree to the following: An Asuris Prescription Drug Plan is a Medicare drug plan and has a contract with the Federal government. I understand that this prescription drug coverage is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare Part A or Part B coverage. It is my responsibility to inform Asuris Prescription Drug Plans of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time - if I am currently in a Medicare Prescription Drug Plan, my enrollment in Asuris Prescription Drug Plans will end that enrollment. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes if an enrollment period is available, generally during the Annual Enrollment Period (October 15 - December 7), unless I qualify for certain special circumstances. Asuris Prescription Drug Plans serve a specific service area. If I move out of the area that Asuris Prescription Drug Plans serve, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand that I must use network pharmacies except in an emergency when I cannot reasonably use Asuris Prescription Drug Plans network pharmacies. Once I am a member of an Asuris Prescription Drug Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Asuris Prescription Drug Plans when I get it to know which rules I must follow to get coverage. I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage in the future. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Asuris Prescription Drug Plans, he/she may be paid based on my enrollment in an Asuris Prescription Drug Plan. Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid program and the Medicare Savings Program.


Please read and sign below Release of Information: By joining this Medicare prescription drug plan, I acknowledge that Asuris Prescription Drug Plans will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Asuris Prescription Drug Plans will release my information including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on my behalf under State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by Medicare. Signature _______________________________________ Today’s Date: ____________________If you are the authorized representative, you must sign above and provide the following information:

Name: ___________________________________ Relationship to enrollee: _________________

Address: _________________________________ Phone Number (______)_________________

_________________________________

Please submit a copy of any documentation needed to support you as the authorized representative.

Agent Name ______________________________ Agent Number _________________________

Agent Phone Number (including area code) _________________________________

Agent Signature _____________________________________________________ Agent Application Received Date ____________________

Asuris Office Use Only

Name of staff member/agent/broker (if assisted in enrollment): ______________________________

Plan ID#: ___________________________________

Effective Date of Coverage: ____________________

IEP: __________ AEP: __________ SEP (type): __________ Not Eligible: __________


NONDISCRIMINATION NOTICE

Asuris complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Asuris does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Asuris: Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, and accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services listed above, You can also file a civil rights complaint with the please contact: U.S. Department of Health and Human Services,

Office for Civil Rights electronically through the Medicare Customer Service Office for Civil Rights Complaint Portal at 1-800-541-8981 (TTY: 711) https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or

by mail or phone at: Customer Service for all other plans 1-888-232-8229 (TTY: 711) U.S. Department of Health and Human Services

200 Independence Avenue SW, If you believe that Asuris has failed to provide Room 509F HHH Building these services or discriminated in another way Washington, DC 20201 on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with 1-800-368-1019, 800-537-7697 (TDD). our civil rights coordinator below:

Complaint forms are available at Medicare Customer Service http://www.hhs.gov/ocr/office/file/index.html. Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355 (TTY: 711) Fax: 1-888-309-8784 [email protected]

Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-232-8229 (TTY: 711) [email protected]

01012017.04PF12LNoticeNDMAAsuris

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) Individual Enrollment form · Plan (PDP) Individual Enrollment form PO Box 1827 Medford, OR 97501 1-844-ASURIS2 (1-844-278-7472) Fax number 1-888-335-2988 TTY 711 Please contact

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