Medicare Prescription Payment Plan Participation Request Form

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 the CareAdvantage Unit for more information.

You can also call us at 1-866-880-0606 to submit your request via telephone.

If you have questions or need help completing this form, call us at 1-866-880-0606, Monday - Sunday, 8:00 a.m. to 8:00 p.m. TTY users can call 1-800-735-2929.

Fields marked with an asterisk * are required.

Member information

First name*

Middle initial

Last name*

Medicare number*

Date of Birth*

Phone number*

Permanent residence street address

Don’t enter a P.O. Box unless you’re experiencing homelessness.

Street address*

City*

State*

ZIP code*

Mailing address (if different from permanent residence street address)

Street address

City

State

ZIP code

Agreement and signature

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. Health Plan of San Mateo will contact me if they need more information.
Health Plan of San Mateo 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.

Enter your name*

Date signed*

If you’re completing this form for someone else, complete the section below. 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.

Name

Address

Phone

Relationship

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