Medicare Enrollment Change

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This form will be used to change your Medica Prime Solution® Cost plan, change your Part D Rider, or add a Part D Rider. You typically can only change your Part D Rider or add a Part D Rider during the Annual Election Period (AEP) which is October 15 - December 7, or if you qualify for a Special Enrollment Period (SEP). To make a Part D change or add Part D outside of AEP, you must have a valid SEP reason.

You'll be able to review your information and make changes before you submit your completed change form. Have your Medica member ID card ready, as you will need it when filling out this form. Completing this form will take about 5 to 10 minutes.

Please Note: If your permanent residence address has changed, contact Medica Customer Service at the phone number below to discuss your plan options before completing this form.

If you have any questions or if you need enrollment information in another language or a format (like Braille), please contact Medica Customer Service from 8 a.m. to 8 p.m. Central, seven days a week, toll free at 1-855-857-2039 (TTY: 711). Access to representatives may be limited at times.

Complete this section about yourself

Please enter your name exactly the way it appears on your Medica member ID card.

First Name is required.
Last Name is required.
The birthdate field format must be mm/dd/yyyy.
Member ID is required.
Group ID is required.

Medica is a Cost Plan with a Medicare contract. Enrollment in Medica depends on contract renewal.

Y0088_5827
Last Updated: 10/18