Enrollment Form

Need Help?  How to fill out the enrollment form

Please select the state you live in:

Please check wich plan you want to enroll in:

If you get Extra Help from Medicare, your monthly plan premium will be lower than what it would be if you didn’t get Extra Help from Medicare. Depending on your level of Extra Help, your premium may be anywhere between $0 and $ 0.00. If you are full-dual eligible, with Extra Help, your premium would be $0.

SECTION 1

To Enroll, all fields in this section are required (unless marked optional)

Application Information

Sex
Salutation

Will you have other prescription drug coverage in addition to Perennial Advantage?

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance program.

Are you a resident of or expect to be a resident of a long-term care facility (LTC) or an assisted living facility (ALF) in Perennial Advantage network for more than 90 days?

SECTION 2

All fields are optional. Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Are you enrolled in your State Medicaid program?

Do you work?
Does your spouse work?

Please choose your Primary Care Physician (PCP):

Is this your current physician?

Check the appropriate box(es) if you would like us to send you information in a language other than English or in an accessible format:

Applicant Contact Information

Permanent Residence Address (P.O. Box not allowed)

Mailing Address, if different from permanent address

Responsible Party Contact Information (as applicable)

If you’re the authorized representative, you must sign previous page and fill out these fields:

*

By providing your email address, you are opting in to receive electronic communication, when available. If you’d like to opt out of electronic communications, check this box:

**

By providing your cell phone number, you are opting in to receive plan communications via SMS/text message. If you do not wish to receive any plan communications or updates via text message, please opt out:

Please contact Perennial Advantage at 1-844-788-6959 (YTT 711) 1-844-788-6986 (YTT 711) if you need information in an accessible format or language other than what is listed above.

Our office hours are 8:00 am to 8:00 pm ET.

TTY users can call (TTY 711).

Paying Your Plan Premium

For plans with a premium, you can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Perennial Advantage the Part D-IRMAA.

PRIVACY ACT STATEMENT The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

IMPORTANT: Read and sign below

I must keep both Hospital (Part A) and Medical (Part B) to stay in Perennial Advantage. By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Perennial Advantage will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border. I understand that when my Perennial Advantage coverage begins, I must get all of my medical and prescription drug benefits from Perennial Advantage. Benefits and services provided by Perennial Advantage and contained in my Perennial Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Perennial Advantage will pay for benefits or services that are not covered. I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that: 1) This person is authorized under State law to complete this enrollment, and 2) Documentation of this authority is available upon request by Medicare.

Signature

Please be advised that by proceeding you are sending an actual enrollment request to Perennial Advantage. Review the Plan’s Enrollment Kit for Colorado, Enrollment Kit for Ohio,

All information you'll provide here is strictly confidential, secure, and will only be used to enroll you in your chosen plan