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 out 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 your health plan for more information.

Full Name *

Medicare Number *

ATRIO Health Plans Member ID *

Birthdate *

Phone Number *

Please enter your permanent residence street address (don’t enter a P.O. Box unless you’re experiencing homelessness)

Street *

City *

County *

State *

ZIP code *

Is your Mailing Address different from Residence Address?

Mailing Street *

Mailing City *

Mailing County *

Mailing State *

Mailing ZIP code *

Read below

I understand this form is a request to participate in the Medicare Prescription Payment Plan. ATRIO Health Plans 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 (attached).
ATRIO Health Plans 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.

Medicare Prescription Payment Plan Participation Request Form

Company

Resources

Compliance at ATRIO

Disclosures