MPPP Election Request Form

Medicare Prescription Payment Plan participation request form
I am currently enrolled in (choose one):

SeniorCare CompleteAbilityCare
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 your plan for more information.

Complete all fields unless marked optional.
FIRST name:*
Please type your first name.
LAST name:*
Please type your last name.
MIDDLE initial (optional)
Please type your middle initial. This is optional.
Medicare Number*
Please type your Medicare number from your Medicare card.
South Country ID Number
Please enter your South Country ID number from your ID card. It starts with a "G" and ends in "01".
Birth date: (MM/DD/YYYY)

MonthDayYear
Date
Phone number
Enter information about your permanent residence. Don't enter a P.O. Box unless you're experiencing homelessness.
Street address
City
County (optional)
State
ZIP code
Enter information about your mailing address, if different from your permanent address. (P.O. Box allowed)
Mailing address
P.O. Box is allowed.
City
State
ZIP code

Are you completing this form for someone else?

YesNo
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*
Enter your full name.
Address (Street, City, State, ZIP code)*
Enter your complete address.
Phone number*
Enter your phone number were we can reach you.
Relationship to participant*
For example: Son, Brother, Care Manager
Read and sign below
- I understand this form is a request to participate in the Medicare Prescription Payment Plan. My 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.
- My 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.
Signature*
By typing your name, you are signing this document as you would with your signature.
Date*

MonthDayYear
Date you signed this form
If you have questions or need help completing this form, call us at 1-866-567-7242, 8 a.m. to 8 p.m., 7 days a week (October – March); 8 a.m. to 8 p.m., Monday - Friday (April – September). TTY users can call 1-800-627 3529 or 711.
Terms and Conditions
Should be Empty:

Medicare Prescription Payment Plan participation request form

Terms and Conditions