You can have the monthly premium for this Medicare drug plan automatically deducted from your Social Security check. If you don't choose this option, we will send you a bill each month which you can pay by mail or by Electronic Funds Transfer (EFT). Generally you must stay with the option you choose for the rest of the year.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare may cover all or some portion of your plan premium. Please choose if you want the remaining premium, if there is any, deducted from your monthly check.

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

If you answer no, your premium may be increased due to a late enrollment penalty. If you answer yes, we may ask you for proof that your previous prescription drug coverage was at least as good as Medicare's standards prescription drug coverage (creditable prescription drug coverage). You can send copies of your proof with this form or you can wait until we ask for it. You don't have to send your proof to enroll. However, if we ask you for your proof and you don't provide it, your premium may be increased because of a late enrollment penallity. For more information about the late enrollment penalty, visit www.Medicare.gov or call 1-800-MEDICARE.

If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have a prescription drug benefit from your Medicare Advantage plan that will meet your needs. By joining FOX Rx Care, your membership in your Medicare Advantage plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug benefits. Read the information that your Medicare Advantage plan sends you and if you have questions, contact your Medicare Advantage plan. If you currently have health coverage from an employer or union, joining FOX Rx Care could affect your employer or union health benefits.

If you currently have health coverage from an employer or union, joining FOX Rx Care could affect your employer or union health benefits. If you have heath coverage from an employer or union, joining FoxRxCare may change how your current coverage works. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

FOX Rx Care is a Medicare drug plan and is in addition to my coverage under Medicare; therefore, I will need to keep my Medicare coverage. It is my responsibility to inform FOX Rx Care of any prescription drug coverage that I have or may get in the future. I can only be in one Medicare prescription drug plan at a time. Enrollment in this plan is generally for the entire year. I may leave this plan only at certain times of the year, or under certain special circumstances, by sending a request to FOX Rx Care or by calling 1-800-Medicare. TTY users should call 1-877-486-2048.

FOX Rx Care serves a specific service area. If I move out of the area that FOX Rx Care serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of FOX Rx Care, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from FOX Rx Care when I receive it to know which rules I must follow in order to receive coverage with this Medicare drug plan.

By joining this Medicare prescription drug plan, I acknowledge that FOX Rx Care will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. 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 by completing this online enrollment form, I will be enrolled in to a FOX Rx Care Medicare Part D plan (if my application is accepted and approved by CMS). I also understand that I will receive a notice of acceptance or denial in to the plan following submission of the enrollment to CMS.