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Opt in

Opt in to the Medicare Prescription Payment Plan and pay for your prescriptions in monthly installments.

About the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option may help you manage your expenses, but it doesn’t save you money or lower your drug costs. 

 

This payment option might not be the best choice for you if you get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP). Call your plan for more information.

Personal information

Fields marked with an asterisk * are required

You may be prompted for more information if necessary.

The following fields need to be corrected:

Unable to submit form

xxxx-xxx-xxxx

This 11-digit number contains both letters and numbers and should be visible on the front of your Medicare card.

MM/DD/YYYY

xxx-xxx-xxxx

Permanent residence street address

Mailing address (if different from permanent residence street address)

Who is completing this form?*

Please select an answer

Signature and agreement

The following fields need to be corrected:

Entering your name below acts as a legally binding signature, confirming you would like to opt in to the Medicare Prescription Payment Plan.

 

  • I understand this form is a request to participate in the Medicare Prescription Payment Plan. My insurance 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 below.
  • My insurance plan will send me a notice to 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.

 

 

Terms and conditions

The Medicare Prescription Payment Plan is a new payment option in the Inflation Reduction Act that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January – December). Your drug coverage offers this payment option and participation is voluntary. There’s no additional cost to participate in the Medicare Prescription Payment Plan. By opting-in to the Medicare Prescription Payment Plan, you agree to the following terms and conditions:

  • You must have active Part D coverage. 
  • You understand that you have the option to leave the plan at any time but will still be responsible for any drug costs already incurred. 
  • You will be billed monthly. This payment is separate from any plan premiums (if applicable). 
  • Your payments may change each month if your prescriptions change month over month. 
  • You are responsible for paying your bill each month, on or before the due date. 
  • If you miss a payment, you will be sent a reminder to make payment. If you do not pay your bill by the due date listed in that reminder, you will be subject to removal from the Medicare Prescription Payment Plan. 
  • Removal from the Medicare Prescription Payment Plan does not impact your payment requirements. If terminated from the program, you remain obligated to pay past due amounts and may continue to receive bills for outstanding payments. 
  • Late payments made pursuant to the Medicare Prescription Payment Plan are not subject to interest or additional fees. 
  • If you are removed from the Medicare Prescription Payment Plan, this will not impact your current drug coverage. 
  • Removal from the Medicare Prescription Payment Plan may impact your eligibility to opt-in in the program in the future.

Please enter your own information, not the member's. Your signature certifies that you're authorized under state law to fill out this participation form and have documentation of this authority available if Medicare asks for it.

Personal representative or caregiver address

xxx-xxx-xxxx

Entering your name below acts as a legally binding signature, confirming you would like the member to opt in to the Medicare Prescription Payment Plan.

 

  • I understand this form is a request for the member to participate in the Medicare Prescription Payment Plan. Their insurance plan will contact them 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 below.
  • The insurance plan will send the member a notice to let them know when their participation in the Medicare Prescription Payment Plan is active. Until then, I understand that the member is not a participant in the Medicare Prescription Payment Plan.

 

 

Terms and conditions

The Medicare Prescription Payment Plan is a new payment option in the Inflation Reduction Act that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January – December). Your drug coverage offers this payment option and participation is voluntary. There’s no additional cost to participate in the Medicare Prescription Payment Plan. By opting-in to the Medicare Prescription Payment Plan, you agree to the following terms and conditions:

  • You must have active Part D coverage. 
  • You understand that you have the option to leave the plan at any time but will still be responsible for any drug costs already incurred. 
  • You will be billed monthly. This payment is separate from any plan premiums (if applicable). 
  • Your payments may change each month if your prescriptions change month over month. 
  • You are responsible for paying your bill each month, on or before the due date. 
  • If you miss a payment, you will be sent a reminder to make payment. If you do not pay your bill by the due date listed in that reminder, you will be subject to removal from the Medicare Prescription Payment Plan. 
  • Removal from the Medicare Prescription Payment Plan does not impact your payment requirements. If terminated from the program, you remain obligated to pay past due amounts and may continue to receive bills for outstanding payments. 
  • Late payments made pursuant to the Medicare Prescription Payment Plan are not subject to interest or additional fees. 
  • If you are removed from the Medicare Prescription Payment Plan, this will not impact your current drug coverage. 
  • Removal from the Medicare Prescription Payment Plan may impact your eligibility to opt-in in the program in the future.

Date signed:

Form submitted

Your request to opt in to the Medicare Prescription Payment Plan has been submitted for review

Your request for the member to opt in to the Medicare Prescription Payment Plan has been submitted for review

We've received your submission and will begin processing it shortly.

We'll review your submission to opt in to the Medicare Prescription Payment Plan and contact you if we need any further information. If your submission is accepted, you'll be able to participate in the Medicare Prescription Payment Plan program once your insurance plan goes into effect.

We'll review your submission for the member to opt in to the Medicare Prescription Payment Plan and contact you if we need any further information. If your submission is accepted, the member will be able to participate in the Medicare Prescription Payment Plan program once your insurance plan goes into effect.

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