Enrollment Forms 2011

Attached in this area are enrollment applications for each PMC plan. If you have already gone over the Evidence of Coverage and decided to join the PMC family, Welcome!

Enrollment Form for Medicare Advantage Plans with or without prescription drug coverage

MAPD and MA Plans

To enroll in one of our plans, you must:

• continue to pay the Medicare Part B premium

• have Medicare Parts A and B

• not have been diagnosed with end stage renal disease (ESRD)

• reside within the Island’s 78 municipalities

PDP Plans

To enroll in one of our Prescription Drug Plans, you must:

• have Medicare Parts A and/or B

• reside within the Island’s 78 municipalities

Specific criteria for enrollment:

Medicare en el Hogar Plus: you must live in an institution licensed by the assigned State Agency of the Commonwealth of Puerto Rico and/or you must require the same amount of case as someone in a nursing home but resides in your home or another community residence.

Platino: you must be enrolled in Reform with Medicare Parts A and B

You can also enroll by calling:

787-622-7510 (Metro Area)

1-877-568-0808 (toll free)

1-866-516-7701 TTY (hearing impaired)

Medicare beneficiaries may enroll in PMC through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

If you have any questions regarding the enrollment form, please call our Member Services Department. When you have finished completing your form, please send it to the following address:

PMC Medicare Choice
Membership Accounting Department
PO Box 366292
San Juan, PR 00936-6292