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OMB 09380990Important Notice From Tufts Health Freedom Plan About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has
information
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How to fill out creditable coverage notice open
How to fill out creditable coverage notice open
01
To fill out a creditable coverage notice, follow these steps:
02
Start by entering the name of the employer or organization providing the notice.
03
Next, provide the employee's name and address.
04
Include the date of the notice and the date the coverage started.
05
Specify the type of coverage being provided (e.g., health, dental, vision).
06
Indicate whether the coverage is creditable or non-creditable.
07
Include any additional information or instructions as required.
08
Finally, sign and date the notice.
Who needs creditable coverage notice open?
01
Anyone who is eligible for Medicare and also has other health insurance coverage needs a creditable coverage notice.
02
This includes individuals who have prescription drug coverage through an employer or union, as well as those who have coverage through a Medicare Advantage plan or Medicaid.
03
The notice is important for individuals to understand how their existing coverage interacts with Medicare's prescription drug coverage.
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