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 submitting 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 notify me 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 enacted through 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 the costs 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:
Upon acceptance into the Medicare Prescription Payment Plan:
• Signature Advantage will inform your pharmacy that you’re using this payment option, which will apply only to Medicare Part D covered drugs that are processed after your election is confirmed.
• When you fill a prescription for an eligible drug, you will pay zero dollars at the pharmacy, but you will still be responsible for your cost share of the drug associated with your Medicare Part D benefit under your plan.
• You will receive a monthly invoice for the amount you owe, when it’s due, and information on how to make a payment.
• Your payments may change every month because your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year. However, you’ll never pay more than the total amount you would have paid out of pocket or the total annual out-of-pocket maximum.
• If you miss a payment, you will receive a reminder notice. If you don’t pay your bill by the date listed, you will be removed from this payment option. However, you are required to pay the amount you owe, and you may not be able to elect back into this payment option.
• You can leave this payment option at any time without affecting your Medicare drug coverage and other Medicare benefits.
• You can do this by selecting Opt-out through the website or calling the phone number listed on the back of your member ID card. However, after you opt out, you will receive an invoice each month for the amount you owe until your balance is paid.
• You’ll pay the pharmacy directly for new out-of-pocket drug costs after you leave this payment option.
• Participation in this payment option will automatically make you eligible for important relevant communications.
• If you are disenrolled from Signature Advantage for any reason, or you enroll in a new plan with drug coverage, your participation in this payment option will end. However, you will continue to receive a monthly invoice for the amount owed until your balance is paid in full.
If you enroll in a new plan with drug coverage, you may be able to rejoin the Medicare Prescription Payment Plan by contacting your new plan.