You selected Devoted CHOICE GIVEBACK Kentucky (PPO) for 2025.

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan.

To join a plan, you must:

  • Be a United States citizen or be lawfully present in the U.S.
  • Live in the plan's service area

IMPORTANT: To join a Medicare Advantage Plan, you must also have both:

  • Medicare Part A (Hospital Insurance)
  • Medicare Part B (Medical Insurance)

To join a Dual-Eligible Special Needs Plan (D-SNP), you must qualify for both Medicare and Medicaid. To join a Chronic Condition Special Needs Plan (C-SNP), you must have a qualifying chronic condition.

When do I use this form?

You can join a plan:

  • Between October 15-December 7 each year (for coverage starting January 1)
  • Within 3 months of first getting Medicare
  • In certain situations where you're allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

  • Your Medicare Number (the number on your red, white, and blue Medicare card)
  • Your permanent address and phone number

Note: You must complete all items in Step 1 (Personal). The items in Step 3 (Options) are optional — you can't be denied coverage because you don't fill them out.

Reminders

  • If you want to join a plan during fall open enrollment (October 15-December 7), the plan must get your completed form by December 7.
  • If you need to pay a plan premium, your plan will send you a bill. You can choose to sign up to have your premium payments deducted from your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?

Once we process your request to join, we'll contact you.

How do I get help with this form?

Call Devoted Health at 1-800-990-0723 (TTY 711). Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Individuals experiencing homelessness:

If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., Social Security checks) may be considered your permanent residence address.