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Prescription Advantage is a state-sponsored prescription drug program administered by the Commonwealth of Massachusetts Executive Office of Elder Affairs for seniors and people with disabilities.
Prescription Advantage Application
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
Name of the person completing application: *
Role of the person completing application: *
Authorized Representative
Designee
Elder Affairs
MCPHS
Other
Part D Plan
Relative/Friend
SHINE counselor
State Official
Veterans Services
Applicant Information
First Name: *
Last Name: *
Middle Initial:
Suffix:
I
II
III
IV
Jr.
Sr.
Date of Birth: *
Gender: *
Male
FeMale
Social Security Number:
RailRoad Retirement #:
Preferred Written Language:
English
Armenian
Chinese
Cambodian
French
Greek
Haitian
Italian
Laotian
Polish
Portugese
Russian
Spanish
Vietnamese
Other
Are you enrolled in Medicare? *
Yes
No
Medicare ID #: *
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