I understand this form is a request to participate in the Medicare Prescription Payment Plan. My plan will contact me if they need more information.
- I understand that signing this form means that I’ve read and understand the form and the terms and conditions listed below.
- My plan will let me know when my participation in the Medicare Prescription Payment Plan is active. Until then, I understand that I’m not a participant in the Medicare Prescription Payment Plan.
- I understand that if I stay in the same health or drug plan, my plan will automatically renew my participation in the Medicare Prescription Payment Plan at the beginning of each calendar year, unless I contact my plan to opt out.
Participation terms and conditions
If your request is approved:
- You will no longer pay the pharmacy when you fill your Medicare-covered Part D prescriptions. Your plan will pay your cost share and send you a monthly bill.
- You understand that your Medicare Prescription Payment Plan monthly billing amounts may vary.
- You understand that failing to pay your Medicare Prescription Payment Plan monthly bill in full may result in your removal from the program.
- You may opt out of this program at any time and go back to paying the pharmacy directly for your Medicare-covered Part D medications. You will still be responsible to pay any outstanding Medicare Prescription Payment Plan balance.
