Enrollment for Medicare 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 prescription drug plan (PDP) 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/or Part B as of the effective date of coverage under the Plan; and

•           You permanently reside in the Utah or Idaho 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

Local Telephone Number: 1-801-262-7475

Toll-free Customer Service Number: 1-888-236-4823

TTY/TDD Telephone Number: 711-888-236-4823

Customer Service Hours: 8:00 a.m. to 5:00 p.m (MST)

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 Dept.

Educators Mutual Insurance Association

852 E. 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:

Local Telephone Number: 1-801-262-7475

Toll-free Customer Service Number: 1-888-236-4823

TTY/TDD Telephone Number: 711-888-236-4823

Customer Service Hours: 8:00 a.m. to 5:00 p.m (MST)

Face-to-Face Interview or Telephone Enrollment

Please contact

Local Telephone Number: 1-801-262-7475

Toll-free Customer Service Number: 1-888-236-4823

TTY/TDD Telephone Number: 711-888-236-4823

Customer Service Hours: 8:00 a.m. to 5:00 p.m (MST)

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 Part D program;

•           Understands that enrollment in the PDP 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 PDP; and

•           Knows he/she has the right to appeal service and payment denials made by the organization.