if you have...

• Medicaid with outpatient prescription drug coverage from your State, check the 1^st 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 1^st box.
• TRICARE for Life health benefits including prescription drug coverage, check the 2^nd box.
• Federal Employee Health Benefit Program (FEHBP) health benefits including prescription drug coverage, check the 3^rd box.
• Employer or Retiree Health Insurance that covers prescription drugs, check the "Other health coverage..." box.
• A Medicare Advantage plan DON’T check the "Other health coverage..." box.
• A Medicare Supplement Insurance (Medigap) policy, DON’T check the "Other health coverage..." box.

Page Last Updated: April 20, 2007