2022 Lycoming Tioga MA Kit

Section 1 – All fields on this page are required (unless marked optional) Page 1 of 5 Select the plan you want to join: __ $0 - HMO No Rx (HMO) ( Does not include Part D prescription drug coverage) __ $0 - HMO Premier Rx (HMO) __ $22 - HMO Deductible Rx (HMO) __ $38 - HMO Rx Choice (HMO) __ $81 - HMO Rx (HMO) __ $302 - HMO Rx Enhanced (HMO) __ $0 - PPO Flex Rx (PPO) LAST Name: FIRST Name: Middle Initial (optional): Birth Date: Sex: Phone Number: (_ _/_ _/ _ _ _ _)  M  F ( ) (MM/DD/YYYY) Permanent Residence Street Address (Don’t enter a PO Box): City: County (optional): State: ZIP Code: Mailing address, if different from your permanent address (PO Box allowed): Street Address: City: State: ZIP Code: Answer these important questions: Will you have other prescription drug coverage (like VA, TRICARE) in additional to UPMC for Life?  Yes  No Name of other coverage: Member number for this coverage: Group number for this coverage: ___________________ __________________________ _______________________ Fill out this information as it appears on your red, white, and blue Medicare card: Hospital (Part A) effective date: ___________________________________ Hospital (Part B) effective date: ___________________________________ You must have Medicare Part A and Part B to join a Medicare Advantage plan. Medicare number: _ _ _ _ - _ _ _ - _ _ _ _ Your Medicare information Enrollment 121 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111