- Prescription Advantage - Massachusetts State

Things to note before you start completing this application:

Prescription Advantage is only available to those with a primary residence in Massachusetts. A primary residence is one in which you reside for at least six (6) months during the calendar year.
If you and your spouse are both applying, you must each fill out a separate application.
Information to have on hand while completing this application: Applicant Date of Birth, Medicare ID number and current Part D plan name, if applicable.
Any item followed by an * is required information. You must provide this information before you can continue on to the next page.

Is this form being completed by someone other than the applicant? *

Yes No

Applicant Information

First Name: *

Last Name: *

Middle Initial:

Suffix:

Date of Birth: *

Gender: *

Male FeMale

Social Security Number:

RailRoad Retirement #:

Preferred Written Language:

Are you enrolled in Medicare? *

Yes No

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Prescription Advantage Application