Medicare Supplement Open Enrollment Election Form

This open enrollment is only for new enrollment or changes in the Highmark Special Medicfill plan. You must be Medicare eligible to participate in the Medicare Supplement plan.

If you are already enrolled in Highmark Delaware Special Medicfill with or without prescription coverage, and have no changes, no action is required. You do not have to complete or submit this form. Your current election will continue into the new calendar year.

Would you like to enroll yourself/spouse/dependent(s) or change your current Highmark Delaware Special Medicfill coverage?

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If you are already enrolled in Special Medicfill with or without prescription coverage, and have no changes, no action is required. You do not have to complete or submit this form. Your current election will continue into the new calendar year.

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If you are not enrolling in Special Medicfill with or without prescription coverage, and have no changes, no action is required. You do not have to complete or submit this form.

Who Is completing this form

Your first and last name

UD Retiree/Long term Disability Participant Name

UD Retiree/Long term Disability Participant Emplid (if available)

Email

Phone #

(xxx)-xxx-xxxx

Retiree Coverage - Highmark Delaware Medicare Supplement - Special Medicfill with or without prescription drug (Part D) coverage.

Number of Dependents

Dependent's name 1

Dependent Relationship 1

Dependent Election 1

Dependent's name 2

Dependent Relationship 2

Dependent Election 2

Dependent's name 3

Dependent Relationship 3

Dependent Election 3

Dependent's name 4

Dependent Relationship 4

Dependent Election 4

Dependent's name 5

Dependent Relationship 5

Dependent Election 5

Working Spouse Surcharge Program

You do not need to complete a Working Spouse Surcharge Verification Form (formerly known as the Spousal Coordination of Benefits form) unless you are newly adding your Medicare-eligible spouse to your coverage for the first time.
Working Spouse Surcharge Form: https://services.udel.edu/TDClient/32/Portal/Re...
Details about the Working Spouse Surcharge program are available at:
https://www.udel.edu/content/dam/udelImages/hum...

Surviving Spouse or Dependent Coverage - Highmark Delaware Medicare Supplement - Special Medicfill with or without prescription drug (Part D) coverage.

Number of other Medicare-eligible dependents

Dependent's name 1

Dependent Election 1

Dependent's name 2

Dependent Election 2

Dependent's name 3

Dependent Election 3

Required Supporting Documentation (for enrollement or changes):

Verification of Medicare Part B enrollment
Marriage certificate when covering a spouse
Social Security card (spouse/dependent child)
Birth or adoption certification when covering a dependent child(ren)

How do I submit my supporting documentation?
If applicable, you can attach supporting documentation to this form, submit them to HR-Benefits department: 550 S. College Ave., Suite 201, or through the Secure Document Submission site.

Attachment

You can upload multiple attachments by selecting all the documents you are uploading (Either click-and-drag or use the Ctrl Key and click on the files you would like to upload).

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Plan	Monthly Cost
Highmark Delaware Medicare Supplement – Special Medicfill with prescription drug (Part D) coverage	$32.15^*
Highmark Delaware Medicare Supplement – Special Medicfill without prescription drug (Part D) coverage	$18.23^*

^* Zero monthly premium cost for retirees who retired on or prior to July 1, 2012.

Your name

Your email address

Verification Code

Medicare Supplement Open Enrollment Election Form

Other Fields