Prior Drug Coverage Attestation

Please complete this form to indicate whether or not you had prescription drug coverage that met Medicare's Minimum Standards of Credible Coverage prior to your enrollment in your current Medicare plan.

Any gaps in coverage may result in a monthly payment penalty. To avoid paying this penalty, please complete and submit this form.

*Indicates a required field

Member Name

000-000-0000

Medicare Beneficiary Identifier

Are you the Member or an Authorized Representative? *

Select one. *

To the authorized representative who is assisting with the attestation:

By answering "Yes", you are attesting that you are authorized to act on behalf of the above member. You also certify that: 1) you are authorized under state law to complete this attestation and 2) documentation of this authority is available upon request by Blue Cross Blue Shield of Massachusetts or by Medicare.*

  You must select Yes to continue

Authorized Representative Information

00000

000-000-0000

Prescription Drug Coverage Information

Did he/she have prior creditable1 prescription drug coverage?*
Did you have creditable1 prescription drug coverage?*

“Creditable1” means that your prior coverage met Medicare’s minimum standards.

MM/DD/YYYY

MM/DD/YYYY

Attestation*

You will be contacted if additional information is needed.