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. Call your plan for more information at (786) 460-3427 or toll free at (833) 342-7463, TTY: 711. We are open 7 days a week, 8:00 a.m. to 8:00 p.m.

You can elect to join in the following ways:

• By phone: By calling (786) 460-3427 toll-free: 1-833-342-7463, TTY: 711.
• By mail: By completing and signing the Medicare Prescription Payment Plan Election Form – English / Spanish
• Online: By completing the form below

Medicare Prescription Payment Plan Form
Please complete all fields unless marked optional.

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Disclaimer *

• I HAVE READ AND AGREE TO THE FOLLOWING: *

• I understand this form is a request to participate in the Medicare Prescription Payment Plan. Doctors HealthCare Plans, Inc. 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. For details on Terms and Conditions please see the following: English / Spanish
• Doctors HealthCare Plans, Inc. 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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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.

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