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)
• Unemployment
• Alimony

If you do not receive W2 or 1099 or W-2 form(s), contact customer service for other documents you may submit.

Other Information

• 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