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      LLC-1050 (09/96) Author: Stephanie Hockaday Last modified by: Andrea Farmer Created Date: 7/24/2015 2:30:00 PM Company: State Corporation Commission Other titles:


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      www.mass.gov/anf/docs/gic/forms/egwp-opt-in-form.docx

      If you enroll in UniCare State Indemnity Plan/Medicare Extension (OME), you will automatically be enrolled in SilverScript Employer PDP sponsored by the Group ...


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      ... [if coverage is group health plan coverage, insert: the Employee Benefits Security Administration at 1-866-444-EBSA (3272)] [and/or] [if coverage is insured, ...


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