REQUIRED MEDICARE FORMS

The following Medicare plans require you to complete a Medicare assignment form: Health Net Medicare Plans (Seniority Plus andCoordination of Benefits), Kaiser Permanente CA Senior Advantage, and Western Health Advantage/WHA Care+.

If you transfer out of one of the Medicare plans above and into Anthem Blue Cross PLUS, Anthem Blue Cross PPO, Core, or High Option Supplement to Medicare, you must submit an Anthem Blue Cross Part D Enrollment form to UC. You must submit a copy of the form for each Medicare member to UC by Dec. 7, 2011.

If you transfer into one of the Medicare plans above from any medical plan: You must submit a Medicare Advantage Universal Enrollment/Election Form to the address of the new plan printed on the instruction sheet (in addition to completing your UC Open Enrollment transaction). If this form is necessary, UC will send one to you along with your UC Open Enrollment confirmation letter. You must submit a copy of the form for each Medicare member to your new medical plan be Dec. 7, 2011.