if you have...
- Medicaid with outpatient prescription drug coverage from your State, check the 1st box.
(Note that some States call this “medical assistance.”)
- A State Pharmacy Assistance Program that helps you pay for prescription drugs, DON’T check the 1st box.
- TRICARE for Life health benefits, check the 2nd box.
- Federal Employee Health Benefit Program (FEHBP) health benefits, check the 3rd box.
- Employer or Retiree Health Insurance that covers prescription drugs, check the "Other health coverage..." box.
- A Medicare + Choice plan DON’T check the "Other health coverage..." box.
- A Medicare Supplement Insurance (Medigap) policy, DON’T check the "Other health coverage..." box.