Medicare Advantage Prescription Drug Plans (Part C) and Cost Plans

Medicare Preferred Provider Organization (PPO) Plan
-A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and includes Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Health Maintenance Organization (HMO) Plan
-A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and includes Part D prescription drug coverage. With most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP)
-A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Additional Products

Dental/Vision

Medicare Supplement (Medigap) Products

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

*Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Beneficiary or Authorized Representative Signature and Signature Date:

Name:

Phone:

Address:

Signature (Type Your Full Name):

Signature Date:

If you are the authorized representative, please fill out the following:

Representative’s Name:

Your Relationship to the Beneficiary:

*Scope of Appointment (SOA) documentation is subject to CMS record retention requirements*

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