2021 Medicare information request form

Have questions about Medicare coverage? Fill out your information below to be contacted by a Medicare Advantage representative of WellFirst Health — Provided by SSM Health Plan.

For more information, call one of our Medicare representatives directly at 1-833-551-0565 (TTY: 711).

I want to receive an information packet and be contacted by a licensed Medicare representative.

First Name *

Last Name *

Phone *

Use xxx-xxx-xxxx format for phone number.

Email *

Address *

Address 2

City *

State *

ZIP Code *

County *

Our Medicare Advantage plans are only available to Medicare-eligible residents of Madison (IL), Saint Clair (IL), Saint Charles (MO), Saint Louis (MO), and Saint Louis City (MO).

I currently have a Medicare plan. No, I do not have a Medicare plan.

I consent to receive Medicare Advantage marketing communications via email and mail and to be contacted by a licensed Medicare Representative from WellFirst Health - Provided by SSM Health Plan. I am aware that I may opt out via unsubscribing from emails or calling Customer Care Center to be removed from the mailing list.

How did you hear about us?

View our Medicare disclaimers.

H8019_wellfirsthealth.com
Updated 12/14/20