2012 Medicare Rx plan enrollment kit

Information you need to enroll your clients in Priority Medicare Part D Drug plans.

Enrollment tips

• Remember to include your agent number on all applications and enrollment forms so we can pay your commission.
• You don't need to mail original enrollment forms if you email them.
• If you submit an online enrollment form, you'll receive immediate confirmation of receipt. We're working on a notification process for email submissions.
• CMS requires you to complete a Sales Confirmation Form for every one-on-one appointment - download a form (97KB PDF).
• Send your clients this link to the 2012 Medicare Part D drug plan enrollment kit - http://www.priorityhealth.com/medicare/2012-rx-kit

PriorityMedicare Rx^SM is a Medicare Part D prescription plan offered by Priority Health under contract with the federal government.

• Once the deductible of $205 is met, the plan begins paying for your prescriptions right away.
• It's a great option when you have Original Medicare, with or without a Medigap (Medicare Supplement insurance) plan.

Enrollment materials

PriorityMedicare Rx brochure (725KB PDF)
Form number: S5857 4000_4001_114 CMS-approved 09142011
General information brochure

Summary of Benefits (233KB PDF)
Form number: S5857_1001_1012_20 CMS-approved 09142011
Summary of covered services, including copays

2012 Medicare Formulary (1MB PDF)
Form number: Y0056_5000_5003_14 File and Use 08122011
An index by drug name begins on page 69.

Enrollment form, instructions and checklist (195KB PDF)
Form numbers: S5857_2000_2001_28 CMS-approved 09152011; S5857_1009_1009_64 File and Use 08072011
You can also enroll online or by phone at 888 389-6676, from 8 a.m to 8 p.m., 7 days a week. TTY users should call 711.

Automatic Bill Payment sign-up form (72KB PDF)
Use this form to sign up to have your premiums automatically deducted from your bank account by electronic funds transfer (EFT).
You can also sign up online when you use the online plan enrollment form. (coming soon)

Appeals and Grievances flyer (97KB PDF)
Form number: Y0056_1009_1009_52 File and Use 09272010

Notice of Privacy Practices (91KB PDF)

Centers for Medicare and Medicaid (CMS) Plan ratings (45KB PDF)
Form number: S5857_9000_9004_6 File and Use 10182011

Three ways to enroll

• By phone - speak to one of our Medicare experts at 888 389-6676, from 8 a.m. to 8 p.m., 7 days a week. TTY users should call 711.
• Online - by going to "Compare plans" , choosing the plan you want and clicking "Enroll."
• Mail - print and fill out the paper enrollment form above and mail it to: Priority Health, MS 1175, 1231 E. Beltline, Grand Rapids, MI 49525.

Or submit applications via email or fax

• Email – scan and email to ph-medicareenrollment@priorityhealth.com 
• Fax – 248 324-2973

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