Medicare Prescription Payment Plan Form - Forms

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 or a State Pharmaceutical Assistance Program (SPAP). Call your plan for more information.

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Member Name*

Prefix First Middle Last Suffix

Medicare Number*

Find your Medicare Number on your government issued Medicare Card. https://www.medicare.gov/basics/get-started-with-medicare/using-medicare/your-medicare-card

CCHP Member Number*

Date of Birth*

Phone*

Residential Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (If different from your permanent address)

If different from your permanent address

Street Address Address Line 2 City State ZIP Code

Read & Sign Below

I understand this form is a request to participate in the Medicare Prescription Payment Plan. CCHP Health Plan will contact me if they need more information.
I understand that signing this form means that I’ve read and understand the form.
CCHP Health 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*

Today's Date*

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

First Last

Relationship to Member

Phone

Address

Street Address Address Line 2 City State ZIP Code

How to submit this form

You can submit this request form online, over the phone, email or by mail.

Submit your completed form to:

MP3
CCHP Member Services
445 Grant Avenue
San Francisco, CA 94108

Email: MemberServices@cchphealthplan.com

You can also complete the participation request form online at pending , or call us at 1-888-775-7888 (TTY 1-877-681-8898) to submit your request via telephone.

If you have questions or need help completing this form, call us at 1-888-775-7888. Hours are 7 days a week, 8:00 a.m. to 8:00 p.m. (October 1 - March 31). Mondays – Fridays 8:00 a.m. to 8:00 p.m. (April 1 - September 30). TTY users can call 1-877-681-8898.

Additional Information

During participation in the Medicare Prescription Payment Plan (MPPP) Program:

You may voluntarily terminate (“Opt-Out”) your participation in the CCHP MPPP Program by calling the CCHP Member Services. CCHP will work with you on how to pay your outstanding balances, if any.
1. You may pay your outstanding balances in full or CCHP will continue to bill you monthly.
2. After Opting Out, you will pay any new out-of-pocket (OOP) directly to the Pharmacy.
CCHP may not bill you more than your calculated maximum monthly cap. CCHP may not bill you late fees, interest payments, or other fees.
CCHP may terminate your participation if you fail to pay your monthly billing amount. We will send you notices reminding you to pay your monthly bill before terminating your participation.
1. Grace Period: If you failed to make payments, you may pay your overdue billing during the grace period. Please call our Member Services Department to determine your grace period.
2. You must continue to pay your monthly billing in order to be eligible to opt into the program for the next year.
If you disenroll from CCHP (voluntary or involuntary), you will also be terminated from the CCHP MPPP Program.
1. You may pay your full outstanding amount in a lump sum or CCHP will continue to bill you for the outstanding balances you owed during your enrollment with CCHP, monthly, not to exceed the maximum monthly cap according to CMS statutory formula or calculation for the duration of the benefit year after your disenrollment.
If CCHP requests additional information for your Election into the MPPP Program, you must return all information requested within the time periods as specified on the CCHP Request Notice.
1. Your election request may be disapproved if CCHP does not receive your information timely.
You may file a Grievance or complaint regarding your participation in the MPPP Program by calling our Member Services Department at the 800 number above. CCHP will notify you of the resolution related to your complaint within 30 calendar days from the receipt of your grievance.