WPS Health Insurance

	WPS MedicareRx Plan (PDP) Individual Enrollment Form

Start Your Information Medicare Information Payment Option Current Prescription Coverage Sign

Completing the application process on the next few pages will send an actual enrollment request to WPS and will be confirmed with the Centers for Medicare & Medicaid Services (CMS).

Start a New Application
To begin a new application, agree to the statement below and click the Start New Application button:
Typically, you may only enroll in a Medicare Prescription Drug Plan during the annual open enrollment period between November 15 and December 31 of each year. However, there are exceptions that may allow you to enroll in a Medicare Prescription Drug Plan outside of the annual open enrollment period.
	I have reviewed the WPS Medicare Prescription Drug Plan pre-enrollment materials. If you have not yet reviewed these materials, click here and review the information on the WPS Medicare Prescription Drug Plan Web site.

Finish My Saved Application
Application number:
For security, only you know your application number. If you do not have it, please start a new application.

To complete your application, you will need the following:
•	Your Medicare Card
•	Current Prescription Coverage Information
•	Adobe Acrobat Reader

Need help?
For technical support contact your Agent or Member Services at 888-915-5477.
M-F 7:00AM-4:30PM CST

Your Agent:

Robert A Hunt

Jack Schroeder & Associates Inc

(920) 465-0251


©2010 Wisconsin Physicians Service Insurance Corporation. All Rights Reserved. \| WPS Home Page
		Last Updated on 11/15/2008