Medicare Advantage Supplemental Dental, Vision and Hearing Enrollment Forms

Who is this for?

If you have one of our Medicare Advantage plans and want more dental, vision and hearing coverage, find the enrollment form here.

Want more dental, vision and hearing coverage to go with your Medicare Advantage plan? We offer optional supplemental buy-up packages you can add for a low monthly price. 

When you can enroll

Current Medicare Advantage plan members can add this coverage at the start of the Annual Enrollment Period, Oct. 15 through Jan. 31.

New members who just purchased one of our Medicare Advantage plans can add this extra coverage within the first 30 days of their enrollment.

How to enroll

Simply select whether you have one of our PPO, HMO or HMO-POS plans, and fill out and return the form. Just keep in mind these enrollment forms are for add-on coverage to a Medicare Advantage plan and not a stand-alone plan. 

What you'll need

  • Your Medicare card
  • Your banking information and a voided check if you want to sign up to have payments taken out of your bank account

Note: If you don't have one of our Medicare Advantage plans yet, you can add this coverage to your plan when you enroll online.

View 2020 forms

View 2019 forms