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Medicare 2017 Enrollment Applications

We have several ways you can enroll in an Amerivantage plan — please choose the one that makes you most comfortable. Or just request more information or an appointment.

Alternate formats and languages for these enrollment forms are available by contacting Amerigroup.

  1. Enroll over the telephone —  If you’d like to speak to one of our expert licensed sales representatives to enroll over the phone, call 1-877-470-4131 (TTY 711 between 8:00 a.m. and 8:00 p.m. local time, 7 days a week.


  2. Set up an appointment — Would you rather have someone visit you in person and describe our plans? Call 1-877-470-4131 (TTY 711 or arrange a personal, in-home sales presentation at your convenience.


  3. Medicare beneficiaries may also enroll in Amerivantage through the Medicare Plan Finder located at http://www.medicare.gov.


  4. Paper Enrollment Application — Print, complete and mail it in. You can access the enrollment application by clicking your plan's link below (application in Spanish is coming soon) and mailing it to:

    Amerigroup Community Care
    P.O. Box 659403
    San Antonio, TX 78265-9714
    Attn:  Enrollment Department  

TitleMarketName (for use in forms)PlanCounties
New Jersey Dual Coordination - EnglishNew JerseyNJ-SNP1-APP-ENG.pdfDual Coordination (HMO SNP)Bergen, Burlington, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic, Somerset, Union
New Jersey Dual Coordination - EnglishNew JerseyNJ-SNP2-APP-ENG.pdfDual Coordination (HMO SNP)Atlantic, Cumberland, Gloucester, Mercer, Morris
New Mexico Classic - EnglishNew MexicoNM-CL-APP-ENG.pdfClassic (HMO)All
Tenneessee Classic - EnglishTennesseeTN-CL1-APP-ENG.pdfClassic (HMO)Benton, Cannon, Cheatham, Claiborne, Clay, Davidson, Decatur, DeKalb, Dickson, Dyer, Fayette, Fentress, Gibson, Giles, Hamilton, Hardin, Henry, Hickman, Houston, Jackson, Jefferson, Knox, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury, McNairy, Meigs, Montgomery, Overton, Perry, Polk, Robertson, Rutherford, Shelby, Stewart, Sumner, Tipton, Van Buren, Warren, Wayne, White, Williamson, Wilson
Tenneessee Classic - EnglishTennesseeTN-CL2-APP-ENG.pdfClassic (HMO)Anderson, Bedford, Bledsoe, Blount, Bradley, Campbell, Cocke, Coffee, Cumberland, Franklin, Grainger, Grundy, Hancock, Hawkins, Humphreys, Lauderdale, Loudon, Marion, Monroe, Moore, Morgan, Obion, Pickett, Rhea, Roane, Scott, Sequatchie, Sevier, Smith, Trousdale, Union, Weakley
Tenneessee Dual Coordination - EnglishTennesseeTN-SNP-APP-ENG.pdfDual Coordination (HMO SNP)Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Carroll, Carter, Cheatham, Chester, Claiborne, Clay, Cocke, Coffee, Crockett, Cumberland, Davidson, De Kalb, Decatur, Dickson, Dyer, Fayette, Fentress, Franklin, Gibson, Giles, Grainger, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hardin, Hawkins, Haywood, Henderson, Henry, Hickman, Houston, Humphreys, Jackson, Jefferson, Johnson, Knox, Lake, Lauderdale, Lawrence, Lewis, Lincoln, Loudon, Macon, Madison, Marion, Marshall, Maury, Mc Nairy, Meigs, Monroe, Montgomery, Moore, Morgan, Obion, Overton, Perry, Pickett, Polk, Rhea, Roane, Robertson, Rutherford, Scott, Sequatchie, Sevier, Shelby, Smith, Stewart, Sullivan, Sumner, Tipton, Trousdale, Unicoi, Union, Van Buren, Warren, Washington, Wayne, Weakley, White, Williamson, Wilson
Texas Classic - EnglishTexasTX-CL10-APP-ENG.pdfClassic (HMO)Hays, Williamson
Texas Classic and Select - EnglishTexasTX-CL1-APP-ENG.pdfClassic and Select (HMO)Bexar
Texas Classic and Select - EnglishTexasTX-CL2-APP-ENG.pdfClassic and Select (HMO)El Paso
Texas Classic and Select - EnglishTexasTX-CL3-APP-ENG.pdfClassic and Select (HMO)Harris
Texas Classic - EnglishTexasTX-CL4-APP-ENG.pdfClassic (HMO)Brazoria, Fort Bend, Galveston, Jefferson, Montgomery
Texas Classic - EnglishTexasTX-CL5-APP-ENG.pdfClassic (HMO)Denton, Tarrant
Texas Classic - EnglishTexasTX-CL6-APP-ENG.pdfClassic (HMO)Comal, Medina
Texas Classic - EnglishTexasTX-CL7-APP-ENG.pdfClassic (HMO)Hudspeth
Texas Classic - EnglishTexasTX-CL8-APP-ENG.pdfClassic (HMO)Lubbock
Texas Classic and Select - EnglishTexasTX-CL9-APP-ENG.pdfClassic and Select (HMO)Travis
Texas Dual Coordination - EnglishTexasTX-SNP1-APP-ENG.pdfDual Coordination (HMO SNP)Bexar, El Paso, Travis
Texas Dual Coordination - EnglishTexasTX-SNP2-APP-ENG.pdfDual Coordination (HMO SNP)Harris
Texas Dual Coordination - EnglishTexasTX-SNP3-APP-ENG.pdfDual Coordination (HMO SNP)Brazoria, Comal, Denton, Fort Bend, Galveston, Hays, Hudspeth, Jefferson, Lubbock, Medina, Montgomery, Tarrant, Williamson
Washington Classic - EnglishWashingtonWA-CL-APP-ENG.pdfClassic (HMO)All
Washington Dual Coordination - EnglishWashingtonWA-SNP-APP-ENG.pdfDual Coordination (HMO SNP)All
New Mexico Classic - SpanishNew MexicoNM-CL-APP-SPA.pdfClassic (HMO)All
New Jersey Dual Coordination - SpanishNew JerseyNJ-SNP1-APP-SPA.pdfDual Coordination (HMO SNP)Bergen, Burlington, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic, Somerset, Union
New Jersey Dual Coordination - SpanishNew JerseyNJ-SNP2-APP-SPA.pdfDual Coordination (HMO SNP)Atlantic, Cumberland, Gloucester, Mercer, Morris
Texas Classic - SpanishTexasTX-CL10-APP-SPA.pdfClassic (HMO)Hays, Williamson
Texas Classic and Select - SpanishTexasTX-CL1-APP-SPA.pdfClassic and Select (HMO)Bexar
Texas Classic and Select - SpanishTexasTX-CL2-APP-SPA.pdfClassic and Select (HMO)El Paso
Texas Classic and Select - SpanishTexasTX-CL3-APP-SPA.pdfClassic and Select (HMO)Harris
Texas Classic - SpanishTexasTX-CL4-APP-SPA.pdfClassic (HMO)Brazoria, Fort Bend, Galveston, Jefferson, Montgomery
Texas Classic - SpanishTexasTX-CL5-APP-SPA.pdfClassic (HMO)Denton, Tarrant
Texas Classic - SpanishTexasTX-CL6-APP-SPA.pdfClassic (HMO)Comal, Medina
Texas Classic - SpanishTexasTX-CL7-APP-SPA.pdfClassic (HMO)Hudspeth
Texas Classic - SpanishTexasTX-CL8-APP-SPA.pdfClassic (HMO)Lubbock
Texas Classic and Select - SpanishTexasTX-CL9-APP-SPA.pdfClassic and Select (HMO)Travis
Tenneessee Dual Coordination - SpanishTexasTX-SNP1-APP-SPA.pdfDual Coordination (HMO SNP)Bexar, El Paso, Travis
Tenneessee Dual Coordination - SpanishTexasTX-SNP2-APP-SPA.pdfDual Coordination (HMO SNP)Harris
Tenneessee Dual Coordination - SpanishTexasTX-SNP3-APP-SPA.pdfDual Coordination (HMO SNP)Brazoria, Comal, Denton, Fort Bend, Galveston, Hays, Hudspeth, Jefferson, Lubbock, Medina, Montgomery, Tarrant, Williamson

We’re available to serve you from 8:00 a.m. to 8:00 p.m. local time, 7 days a week.

You may enroll in the plan only during certain times of the year. Contact Amerigroup for more information. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers, neither Medicare nor Amerigroup will be responsible for the costs. Amerigroup is a culturally diverse company. We welcome all eligible individuals into our health care programs, regardless of health status. If you have questions or concerns, please call 1-800-374-3631 (TTY 711) from 9:00 a.m. to 5:00 p.m. Eastern time, Monday through Friday and ask for extension 34925.

Please be sure to read important documents about the plan before completing an enrollment. You can find these documents by choosing the state where you live, then clicking on the link called “Documents & More” on the left-hand side of this page. The Summary of Benefits will give you information about covered benefits, and the Plan Ratings document will tell you how our plan is rated by Medicare.