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 1-800-678-2265      TTY 711

7 days a week

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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.

Questions?

If you do have questions, call us at 1-800-200-4255 (TTY: 711). April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, ℠ Registered and Service Marks of the Blue Cross and Blue Shield Association. ®' Registered Marks of Blue Cross Blue Shield of Massachusetts. ®’’, ℠´, ™ Registered Service and Trade Marks are property of their respective owners. ©   Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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