Get Envisionrxplus Enroll

Filling out the Envisionrxplus Enroll form is a crucial step in securing your Medicare prescription drug coverage. This guide provides clear, step-by-step instructions to help you complete the enrollment form accurately and efficiently.

Follow the steps to complete the online enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it for filling out.
2. Provide your personal information. Start by entering your last name, first name, and middle initial. Ensure all names are spelled correctly. Enter your birth date in the format MM/DD/YYYY.
3. Select your sex by checking the appropriate box for either Male or Female. Next, input your home phone number, including the area code, ensuring it is current and accessible.
4. Fill out your permanent residence street address. A P.O. Box is not accepted, so provide a complete home address, followed by the city, state, and ZIP code.
5. If your mailing address is different, provide that information in the designated section. Include the street address, city, state, and ZIP code.
6. Enter the details for an emergency contact, including their name, phone number, and relationship to you.
7. Input your email address. This will facilitate communication regarding your enrollment.
8. Next, complete the Medicare insurance information section. Refer to your Medicare card to provide the required details such as your Medicare claim number and entitlement dates for Medicare Part A and Part B.
9. Select a payment option for your plan premium. Options include receiving a bill, electronic funds transfer (EFT), credit card payments, or automatic deduction from your Social Security or Railroad Retirement Board benefits.
10. Answer the questions regarding other prescription drug coverage. Indicate if you have additional coverage and provide the necessary details if applicable.
11. Review the important information provided at the end of the form. This includes implications of joining EnvisionRxPlus if you have other health coverage or are enrolled in a Medicare Advantage plan.
12. Sign and date the application to confirm you understand the terms of enrollment. If someone else is signing on your behalf, they must provide their information and your relationship.
13. Once completed, save your changes, download a copy for your records, and print the form if necessary. You may also share it as needed.

Complete your Envisionrxplus Enrollment form online today and ensure you have the coverage you need.