Medicare Prescription Payment Plan participation request form (Missouri)

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 extra 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.
Complete all fields unless marked optional
Name*

First NameMiddle Name (Optional)Last Name
Email (Optional)
example@example.com
Medicare Number*
Birth Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Permanent residence street address (don’t enter a P.O. box unless you’re experiencing homelessness)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Read and sign below
- I understand this form is a request to participate in the Medicare Prescription Payment Plan. The 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 attached terms and conditions.
- The 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.
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Medicare Prescription Payment Plan participation request form

Complete all fields unless marked optional

Read and sign below