Contact for Documentation required to apply
The Details of Documentation required to apply
How to apply Documentation required to apply
1-800-243-4636 and press 2 or press 5 if calling from a cell phone; TTY at 1-877-610-0241
P.O. Box 15153
Worcester, MA 01615-0153
Next steps for Documentation required to apply
Information you will need to have handy to complete the application includes:
- Your Medicare number if you have Medicare
- The name of other health insurance or prescription drug coverage you may have
- Your Railroad Retirement number if you have one
You will be asked to send Prescription Advantage information about your income. Acceptable income documents include:
- Your most recently federal income tax return 1040, 1040A, or 1040EZ
- Social Security benefit award letter or annual benefit statement (SSA-1099)
If you do not file federal income taxes, send copies of your most recent 1099 or W2 forms for any income you receive. Income may include:
- Pensions/ Annuities
- Railroad Benefit Income
- Rental Income
- Dividends/ Interest
- Employment Income
- Capital Gains
- Retirement (IRA; 401K; 403B)
If you do not receive W2 or 1099 or W-2 form(s), contact customer service for other documents you may submit.
- If you have Medicare Part A or B, send a copy of the front of your Medicare ID card.
- If you have other prescription drug coverage, send a copy of the front and back of your insurance card.
- If you applied for Extra Help, send a copy of the determination letter from Social Security. If you do not have a determination letter, send a copy of your Extra Help application receipt from Social Security.
- If you would like to have an Authorized Representative be responsible for your Prescription Advantage benefits you can send a signed Authorized Representative form with your application.
Applicants under age 65
Applicants under age 65 with a disability must submit a copy of 1 of the following documents:
- Your Medicare card
- Current Social Security award letter for SSDI or SSI benefits
- Certificate of blindness from the Massachusetts Commission for the Blind
- Determination of disability from MassHealth or CommonHealth (Medicaid)
- Written verification of SSDI or SSI benefits signed by an authorized Social Security Claims Representative on Social Security letterhead
More info about Documentation required to apply
A SHINE (Serving the Health Insurance Needs of Everyone) Counselor can also help you with your application. To find a SHINE Counselor near you call:1-800-AGE-INFO (1-800-243-4636) and press 3; TTY/HCO: 1-800-548-2546.