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Enrollment Forms
Click here for Spanish version 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 |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore City, Baltimore County, Maryland, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| Pennsylvania: |
Allegheny, Bucks, Cumberland, Delaware, Lancaster, Montgomery, Philadelphia, Washington, Westmoreland, York |
| Bravo Classic Plus |
New Jersey: |
Burlington, Camden, Gloucester |
| Texas: |
Bexar, Chambers, Collin, Dallas, Denton, El Paso, Ellis, Fort Bend, Galveston, Harris, Hood, Johnson, Liberty, Montgomery, Parker, Rockwall, Tarrant, Wise |
| Bravo Achieve |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore City, Baltimore County, Maryland, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| New Jersey: |
Burlington, Camden, Gloucester |
| Pennsylvania: |
Allegheny, Bucks, 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 Premier Plus |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore City, Baltimore County, Maryland, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| New Jersey: |
Burlington, Camden, Gloucester |
| Bravo Freedom |
District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore City, Baltimore County, Maryland, Harford, Montgomery, Prince George's |
| Texas: |
Collin, Dallas, Denton, Tarrant |
| Bravo Silver |
Pennsylvania: |
Bucks, Montgomery, Philadelphia |
| Bravo Select |
Delaware: |
Kent, New Castle, Sussex |
| District of Columbia: |
Washington, D.C. |
| Maryland: |
Anne Arundel, Baltimore City, Baltimore County, Maryland, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| Pennsylvania: |
Allegheny, Bucks, 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 Complete |
New Jersey: |
Burlington, Camden, Gloucester |
| Bravo Gold |
Pennsylvania: |
Bucks, Montgomery, Philadelphia |
| Bravo Premier |
Pennsylvania: |
Allegheny, Bucks, Delaware, Montgomery, Philadelphia, 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 City, Baltimore County, Maryland, Carroll, Cecil, Harford, Howard, Montgomery, Prince George's |
| New Jersey: |
Burlington, Camden, Gloucester |
| Pennsylvania: |
Allegheny, Bucks, Cumberland, Delaware, Lancaster, Montgomery, Philadelphia, Washington, Westmoreland, York |
| Texas: |
Bexar, El Paso, Fort Bend, Galveston, Harris, Liberty, Montgomery |
| Bravo Traditions PPO |
Texas: |
Collin, Dallas, Denton, Tarrant |
| BravoRx |
Alabama,
Arizona,
Arkansas,
California,
Colorado,
Connecticut,
Delaware,
District of Columbia,
Georgia,
Idaho,
Illinois,
Indiana,
Iowa,
Kansas,
Kentucky,
Louisiana,
Maryland,
Massachusetts,
Michigan,
Minnesota,
Mississippi,
Missouri |
Montana,
Nebraska,
Nevada,
New Jersey,
New Mexico,
New York,
North Carolina,
North Dakota,
Ohio,
Oklahoma,
Pennsylvania,
Rhode Island,
South Carolina,
South Dakota,
Tennessee,
Texas,
Utah,
Vermont,
Virginia,
West Virginia,
Wisconsin,
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.
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Social Security at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call 1-800-325-0778.
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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 Member Services 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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