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2012 Enrollment Forms - En Español
Click here for English version 2012 Enrollment Forms
To enroll by mail: Download the enrollment form for your desired Bravo Health plan by clicking on the service area. Print out the enrollment form, complete it and mail it to Bravo Health at:
| Bravo Classic |
Delaware: |
Kent, New Castle, Sussex |
| Maryland: |
Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery, Prince George's Carroll, Cecil, Howard |
| Pennsylvania: |
Bucks, Montgomery, Philadelphia
Chester, Delaware
Allegheny, Washington, Westmoreland
Cumberland, Lancaster, York |
| Bravo Classic Plus |
Delaware: |
Kent, New Castle, Sussex |
| New Jersey: |
Atlantic, Burlington, Camden, Gloucester |
| Texas: |
Bexar, Chambers, Collin, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Harris, Hood, Johnson, Liberty, Montgomery, Parker, Rockwall, Tarrant, Wise |
| District of Columbia: |
Washington, DC |
| Bravo Achieve |
Delaware: |
Kent, New Castle, Sussex |
| Maryland: |
Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery, Prince George's
Carroll, Cecil, Howard |
| New Jersey: |
Atlantic, Burlington, Camden, Gloucester |
| Pennsylvania: |
Bucks, Montgomery, Philadelphia
Chester, Delaware
Allegheny, Washington, Westmoreland
Cumberland, Lancaster, York |
| Texas: |
Bexar, Chambers, Collin, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Harris, Hood, Johnson, Liberty, Montgomery, Parker, Rockwall, Tarrant, Wise |
| Bravo Achieve Plus |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Bravo Premier Plus |
New Jersey: |
Atlantic, Burlington, Camden, Gloucester |
| Bravo Freedom |
District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery, Prince George's |
| Bravo Silver |
Pennsylvania: |
Bucks, Montgomery, Philadelphia |
| Bravo Select |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore, Baltimore City, Harford, Montgomery, Prince George's
Carroll, Cecil, Howard |
| Pennsylvania: |
Bucks, Montgomery, Philadelphia
Chester, Delaware
Allegheny, Washington, Westmoreland
Cumberland, Lancaster, York |
| Texas: |
Bexar, Chambers, Collin, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Harris, Hood, Johnson, Liberty, Montgomery, Parker, Rockwall, Tarrant, Wise |
| Bravo Complete |
New Jersey: |
Atlantic, Burlington, Camden, Gloucester |
| Bravo Gold |
Pennsylvania: |
Bucks, Montgomery, Philadelphia |
| Bravo Premier |
Pennsylvania: |
Bucks, Montgomery, Philadelphia
Chester, Delaware
Allegheny, Washington, Westmoreland |
| Bravo GoldRx |
Pennsylvania: |
Bucks, Montgomery, Philadelphia |
| Bravo Traditions |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore, Baltimore City, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| New Jersey: |
Atlantic, Burlington, Camden, Gloucester |
| Pennsylvania: |
Allegheny, Bucks, Chester, Cumberland, Delaware, Lancaster, Montgomery, Philadelphia, Washington, Westmoreland, York |
| Texas: |
Bexar, Chambers, Collin, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Harris, Hood, Johnson, Liberty, Montgomery, Parker, Rockwall, Tarrant, Wise |
| Bravo Freedom PPO |
Texas: |
Collin, Dallas, Denton, Tarrant |
| Bravo Traditions PPO |
Texas: |
Collin, Dallas, Denton, Tarrant |
| BravoRx |
Alaska,
Arizona,
Arkansas,
California,
Connecticut,
Delaware,
Florida,
Georgia,
Hawaii,
Idaho,
Illinois,
Indiana,
Iowa,
Kansas,
Kentucky,
Louisiana,
Maine,
Maryland,
Massachusetts,
Michigan,
Minnesota,
Mississippi,
Missouri,
Montana, |
Nebraska,
Nevada,
New Hampshire,
New Jersey,
New Mexico,
New York,
North Dakota,
Ohio,
Oklahoma,
Oregon,
Pennsylvania,
Rhode Island,
South Carolina,
South Dakota,
Texas,
Utah,
Vermont,
Virginia,
Washington,
Washington, D.C.,
West Virginia,
Wyoming |
You May Be Able to Get Extra Help to Pay for Your Prescription Drug Premiums and Costs
People with limited incomes may qualify for Medicare's Extra Help program. Extra Help can help pay for up to 75% of regular drug costs – including monthly premiums, annual deductibles, and co-insurance – and eliminates some costs altogether.
To see if you qualify for getting Extra Help, call:
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1-800-MEDICARE (1-800-633-4227), 24 hours a day/7days a week. TTY users should call 1-877-486-2048. -
Social Security at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call 1-800-325-0778. -
Your state Medicaid office
You can find out what your monthly premium would be with Extra Help based on your plan. For more information, call our Customer Service Department at 1-866-442-7498. Also check out our Member Insight – Important Plan Information page for more detail about conditions on stand-along drug coverage plans.
Plans are offered by Bravo Health, Inc., 3601 O'Donnell Street, Baltimore, Maryland 21224; Bravo Health Pennsylvania, Inc.; Bravo Health Mid-Atlantic, Inc.; Bravo Health Texas, Inc.; and/or Bravo Health Life Insurance Company, Inc. Coverage is provided through a Medicare Advantage organization or a Medicare prescription drug plan sponsor with a Medicare contract. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year.
For assistance with Medicare Advantage Health Plans please call our Member Service Department at:
For assistance with stand alone Prescription Drug Plans please call our Member Service Department at:
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