- Prescription Advantage - Massachusetts State

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

Applicant Information (Continued)

Primary Street Address (no P.O. box)

Number and Street: *

Apt.:

Zip: *

City: *

State: *

Phone: *

Is mailing address different?

Yes No

Household Information

Do you have a spouse who lives with you? *

Yes No

How many relatives(besides your spouse) live with you and depend on you or your spouse to provide at least one-half of their financial support? If none, enter 0. *

Household Information

Are you enrolled in a Medicare Drug Plan or Creditable Coverage Drug Plan? *

Yes No Not Sure

Do you have any other health insurance? *

Yes No Not Sure

Do you receive health coverage through Medicaid (MassHealth or CommonHealth)? *

Yes No Not Sure

Do you receive health coverage through a MassHealth Buy-In Program, also known as Medicare Savings Program (MSP)? *

Yes No Not Sure

Eligibility for MSP may impact your eligibility for Prescription Advantage.

Assets / Income

Are your savings, investments, and real estate(other than your home) worth more than the resource limits for Extra Help? *

Yes No Not Sure

Are your savings, investments, and real estate(other than your home) worth more than the resource limits for MassHealth Buy-In Programs, Also known as Medicare Savings Program (MSP)? *

Yes No Not Sure

Include assets you own by yourself, with your spouse, or with someone else.

Please click here for current resource limits for both of these programs.

Are you currently working? *

Yes No

Is Social Security your only source of income? *

Yes No

Did you or your spouse file federal income taxes? *

Yes No

Signature

Terms of Agreement

Please read and accept the following statements by clicking ‘I Agree’. Because we require information regarding your household income, your spouse must also agree if he/she lives with you, even if he/she is not applying at this time.

I agree to abide by all Prescription Advantage regulations and will notify Prescription Advantage, in writing, within fifteen (15) business days of any change to my personal information which may affect my eligibility or level of benefits. This information includes, but is not limited to, changes in residence, marital status, income, and Medicare status.

I understand and consent to the fact that:

1. Prescription Advantage may share my personal information with other state and federal agencies, as well as with any other organization providing me prescription drug coverage, for the purpose of coordinating my Prescription Advantage benefits with my other prescription drug coverage; and

2. Prescription Advantage may use my name, date of birth, address, social security number, and other identifying information to verify the information I have provided on this application, such as any information that I have provided about my income, with other state and federal agencies, including but not limited to the Massachusetts Department of Revenue and the United States Social Security Administration. Prescription Advantage may use the identifying information in conducting matches to confirm my eligibility for assistance and to detect fraud. Prescription Advantage may also match the identifying information that I provided on this application relating to my family members, such as my spouse, or my dependents.

I hereby certify, under the pains and penalties of perjury, that I have examined all the information on this form and the accompanying documentation and that it is true, complete, and correct to the best of my knowledge and belief. I further certify that any information I submit in the future related to this form and the accompanying documentation will also be true, complete, and correct to the best of my knowledge and belief.

If you are acting on behalf of someone who is unable to complete this form because of a physical or mental condition, by agreeing to the statements on this form, you are declaring that the information submitted and any accompanying or supplemental information is true, complete, and correct to the best of your knowledge and belief.

Applicant or Designee:

Agree

For questions, call Prescription Advantage Customer Service at 1-800-243-4636, or TTY for the deaf and hard of hearing at 1-877-610-0241.

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Prescription Advantage Application