• How can I enroll in Medicare Blue PPO?
• Who is eligible to enroll?
• Enrollment Periods

How can I enroll in Medicare Blue PPO?

We offer three easy ways to enroll in Medicare Blue PPO:

1. Phone: Call 1-866-303-2583, Monday - Friday, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-800-722-0353.
2. Mail: Download the enrollment form , complete and mail to the address below:

   Medicare Blue PPO
   PO Box 3327
   Tulsa, OK 74101-9917

3. Online: Medicare beneficiaries may enroll in Medicare Blue PPO through the Centers for Medicare and Medicaid Services online enrollment center at www.medicare.gov*. Enrollment for January 1, 2010, does not begin until November 15, 2009. For more information, contact a Product Specialist at 1-866-303-2583, 8 a.m. - 8 p.m., Central time, 7 days a week. For hearing or speech impaired, call 1-800-722-0353.

Our plan is offered by HCSC Insurance Service Company, a Medicare Advantage Preferred Provider Organization (PPO) plan. The attached Summary of Benefits and Enrollment Guide highlight features of our plan. It does not list every service that we cover or list every limitation or exclusion. To obtain a complete list of benefits, you may download the Evidence of Coverage.

• MedicareBlue PPO with Rx Evidence of Coverage 
• MedicareBlue PPO without Rx Evidence of Coverage 

For more details about Medicare Blue PPO benefits, please review the benefit summary.

• MedicareBlue PPO with Rx Benefit Summary 
• MedicareBlue PPO without Rx Benefit Summary 

Make paying your premiums easy!
Download, complete and sign the Automatic Premium Payment Program Form . You can even send it in with your application.

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Who is eligible to enroll?

You must be entitled to Medicare under Part A and enroll in Part B. Service areas include the following counties:

You must also maintain your Medicare Part A and Part B Coverage by paying monthly Part B premiums, and if applicable, Part A premiums, if not otherwise paid for under Medicaid or another third party.

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Enrollment Periods

 If you are eligible for Medicare Blue PPO, you can enroll during any one of the following three enrollment periods:

Initial Enrollment Period (IEP)

• When you turn 65 years old or first become eligible for Medicare, you are eligible to enroll in Medicare Blue PPO.
• You can enroll up to three months prior to the month of your 65th birthday, the month of your birthday, and up to three months after the month of your 65th birthday.
• These time frames may vary for those enrolling due to disability.
• If you do not enroll during this time frame, you may not be able to enroll until the next Annual Enrollment Period.

Contact a Medicare Blue PPO Product Specialist for more detailed disability enrollment information.

Annual Enrollment Period (AEP)

The Annual Enrollment Period is November 15 through December 31, of every year.

Special Enrollment Period (SEP)

There may be select circumstances when a Medicare beneficiary can enroll outside of the initial and annual enrollment periods. Below is a list of some, but not all, of those circumstances:

• A move outside of the plan's approved program service area
• Entering or leaving a qualified institution, such as a nursing home
• Enrolling in, or dis-enrolling from, a Medicare Advantage plan (medical and drug benefit)
• Becoming eligible for Low Income Subsidy Assistance
• Becoming enrolled in Medicare and Medicaid

To obtain more detailed information on the Special Enrollment Period, please contact our Medicare Blue PPO Product Specialists.

Open Enrollment Period (OEP) The Open Enrollment Period from January 1 through March 31 of each year can be used by Medicare Advantage eligible individuals to make one Medicare Advantage Open Enrollment Period election to the same type of plan in which the individual is already enrolled, as follows:

• If you are enrolled in a Medicare Advantage plan that does not include prescription drug coverage, you can enroll in another Medicare Advantage plan without prescription drug coverage. Or, you can use the Open Enrollment Period to enroll in the original Medicare program (with the option of adding a Medicare Supplement or Medigap plan).
• If you are enrolled in a Medicare Advantage plan that includes prescription drug coverage, you can enroll in another Medicare Advantage plan that includes prescription drug coverage. Or, you can use the Open Enrollment Period to enroll in the original Medicare program (with the option of adding a Medicare Supplement or Medigap plan) plus another prescription drug plan.
• The Open Enrollment Period can not be used to add or remove prescription drug plan coverage.

Because documentation is required to enroll during this period, please contact our Product Specialists for specific details at 1-866-303-2583, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-800-722-0353.

If you choose not to enroll during these required time frames, the federal government may impose a late enrollment penalty of 1% per month for every month you delay enrollment, for Rx Coverage. There is no penalty for not enrolling in a Medicare Advantage plan. To learn more about the late enrollment penalty, please call our Product Specialists for specific details at 1-866-303-2583, 8 a.m. - 8 p.m., Central time, 7 days a week. For the hearing or speech impaired, please call 1-800-722-0353.

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The documents are available in alternate formats or languages; please contact a Product Specialist at 1-866-303-2583, 8 a.m. - 8 p.m., Central time, 7 days a week. For hearing or speech impaired, call 1-800-722-0353.