Enrollment for Medicare Advantage and Medicare Advantage Prescription Drug Plans cannot be submitted before November 15, 2008.

In order for your enrollment to be considered complete, all information indicated on the enrollment form is required unless otherwise noted.

In general, you are eligible to enroll in a Medicare Advantage prescription drug plan (MADP) if:

• You are entitled to Medicare Part A and/or enrolled in Part B, provided that you will be entitled to receive services under Medicare Part A and Part B as of the effective date of coverage under the Plan; and
• You permanently reside in the Utah service area

Beneficiaries interested in available Medicare Part D subsidies may contact, 1-800-MEDICARE (1-800-633-4227) (TTY/TDD user should call 1-877-486-2048) 24 hours a day, 7 days a week, their State Medicaid Office, or local Social Security Administration Office.

Paper Enrollment (by mail or fax)

Complete the enrollment form enclosed in the enrollment kit, sign and date the form, and return it to

Attn: Enrollment Department
Educators Mutual Insurance Association
852 East Arrowhead Lane
Murray, Utah 84107-5298

If you have questions regarding completing the form, please contact Educators Mutual Insurance Association at

If you are the authorized representative for the enrollee, you must provide Educators Mutual Insurance Association with a “Durable Power of Attorney” for healthcare decisions, provided that you have authority to act for the beneficiary in this capacity or a court-appointed legal guardianship. Please send the Durable Power of Attorney with healthcare specified to

Attn: Enrollment Department
Educators Mutual Insurance Association
852 East Arrowhead Lane
Murray, Utah 84107

Internet/Electronic Enrollment

On-line enrollment is available at www.educatorsmutual.com.

Group Enrollment for Employer/Union Sponsored PDPs

If you belong to an employer group or union that currently offers retirement benefits through Educators Mutual Insurance Association, please contact our customer service department for further information:

Face-to-Face Interview or Telephone Enrollment

Please contact

Medicare beneficiaries may also contact 1-800-MEDICARE (1-800-633-4227) for more information about Medicare benefits and services, including general information regarding the health or Part D benefit. TTY/TDD users should call 1-887-486-2048. You can call 24 hours a day, 7 days a week.

Member Acknowledgements

Member:

• Agrees to abide by the Educators Mutual Insurance Association’s membership rules as outlined in material provided to the member;
• Consents to the disclosure and exchange of information necessary for the operation of the Medicare Advantage program;
• Understands that enrollment in the MA or MADP automatically disenrolls him/her from any other PDP, MA plan or PACE plan in which he/she is enrolled;
• Understands that if enrollment requests are submitted for more than one plan with the same effective date, the last choice made will generally be the one that takes effect;
• Knows the expected effective date of enrollment in the MA or MAPD; and
• Knows he/she has the right to appeal service and payment denials made by the organization.

• Download Medicare Advantage with Rx Enrollment Form (Available November 15th, 2008)
• Download Medicare Advantage Enrollment Form (Available November 15th, 2008)
• Beneficiary and Provider Leaflet
• Click Here for Online Enrollment