I understand this form is a request to participate in the Medicare Prescription Payment Plan. My plan will contact me if more information is needed.
- I understand that submitting this form means that I have read and understand the terms and conditions listed below.
- My plan will send me a letter to let me know when my participation in the Medicare Prescription Payment Plan is active. Until then, I understand that I am not a participant in the Medicare Prescription Payment Plan.
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 for paying any outstanding Medicare Prescription Payment Plan balance.
