Prior Drug Coverage Attestation

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.

Yes

No

You must select Yes to continue

Authorized Representative Information

Relationship to Member

First Name

Last Name

Street Address

City

State

ZIP Code

e.g. 00000

Did he/she have prior creditable prescription drug coverage?

Yes

No

I had coverage from/through:

From

e.g. MM/DD/YYYY

To

e.g. MM/DD/YYYY

Plan Name (Optional)

Name of SPAP (Optional)

If you are in an SPAP, what state do you live in: (Optional)

Name of other source: (Optional)

He/She had coverage from/through:

From

e.g. MM/DD/YYYY

To

e.g. MM/DD/YYYY

Plan Name (Optional)

Name of SPAP (Optional)

If you are in an SPAP, what state do you live in: (Optional)

Name of other source: (Optional)

Are you the Member or an Authorized Representative?

Authorized Representative Information

Member Information

Medicare Beneficiary Identifier

Prescription Drug Coverage Information

Attestation

Questions?