Declaration of Prior Prescription Drug Coverage

Are you a Wellcare or Wellcare by ‘Ohana member who would like to submit a Late Enrollment Penalty (LEP) attestation?

Use this form to submit the information.

You will be notified once the plan has receipt of this form.

Date:

Enrollee Name:

Mailing Address:

Phone Number:

Medicare Health Insurance Claim #: (from red, white and blue Medicare card)

Name of Plan:

Date From:

Date To:

Please check all boxes that apply to you.

I had creditable* prescription drug coverage from an Employer/Union, including the Federal Employees Health Benefits Program (FEHBP)

Name:

Date From:

Date To:

Need to add additional employers? Yes No

Name:

Date From:

Date To:

Name:

Date From:

Date To:

Name:

Date From:

Date To:

I had creditable* prescription drug coverage from Medicaid, State Pharmaceutical Assistance Program (SPAP), or another plan sponsored by my state

Name of SPAP:

Date From:

Date To:

If you are in an SPAP, what state do you live in:

I had prescription drug coverage through my VA benefits (veterans, survivor, or dependent benefits)

Date From:

Date To:

I had prescription drug coverage through my TRICARE or other military coverage

Date From:

Date To:

I had a Medigap (Medicare Supplemental) policy with creditable* prescription drug coverage

Date From:

Date To:

I had prescription drug coverage through the Indian Health Service, a Tribe or Tribal organization, or an Urban Indian organization (I/T/U)

Date From:

Date To:

I had prescription drug coverage through PACE (Program of All-Inclusive Care for the Elderly)

Date From:

Date To:

I had creditable* prescription drug coverage from a different source not listed above.

Name of other source:

Date From:

Date To:

I have/had extra help from Medicare to pay for my prescription drug coverage.

Date From:

Date To:

I lived in an area affected by Hurricane Katrina at the time of the hurricane (August 2005) and I joined a Medicare prescription drug plan before December 31, 2006.

Name of Parish:

Date From:

Date To:

I never had creditable* drug coverage

* “Creditable” means that your prior coverage met Medicare’s minimum standards

Additional Information:

Please complete this section: "To the best of my knowledge, the information on this form is true and correct. I understand that if I didn’t have creditable coverage and/or don’t give proof of creditable prescription drug coverage if asked, my premium may be higher.

I understand that by completing this form (or completion by a person authorized to act on behalf of the individual under the laws of the State where the individual resides) means that I have read and understand the contents of this declaration."

I attest that this information is accurate.

Date:

If you are the representative, you must provide the following information:

Name:

Address:

City

State:

Zip:

Relationship to Enrollee:

Phone Number: