Medicare Prescription Drug Plan Individual Enrollment Form (Page 2 of 4) in pdf

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail,

“Electronic Funds Transfer (EFT)”, “credit card” or on-line at each month. You

can also choose to pay your premium by automatic deduction from your Social Security or Railroad

Retirement Board benefit check each month. If you are assessed a Part D-Income Related Monthly

Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for

paying this extra amount in addition to your plan premium. You will either have the amount withheld from

your Social Security or Railroad Retirement Board benefit check or be billed directly by Medicare. Do NOT

pay the Part D-IRMAA extra amount to EnvisionRx Plus Clear Choice.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify,

Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual

deductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollment

penalty. Many people are eligible for these savings and don’t even know it. For more information about this

extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should

call 1-800-325-0778. You can also apply for extra help online at

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part

of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that

Medicare doesn’t cover.

If you don’t select a payment option, you will receive a bill each month.

Please select a premium payment option:

□

Receive a bill

□

Electronic funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check or

provide the following:

Account holder name: ____________________________________________________________

Bank routing number: __ __ __ __ __ __ __ __ __ Bank account number: : __ __ __ __ __ __ __ __ __

__ __ __

Account type: □ Checking

□

Credit Card. Please provide the following information:

Type of Card: Visa, MasterCard, Discover, or American Express

_________________________________________________

Name of Account holder as it appears on card:

_________________________________________________

Account number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration Date: __ __ /__ __ __ __ (MM/YYYY)

□

Automatic deduction from your monthly Social Security/Railroad Retirement Board benefit check. (The Social

Security/Railroad Retirement Board deduction may take two or more months to begin. In most cases, if Social

Security/the Railroad Retirement Board accepts your request for automatic deduction, the first deduction from your

Social Security/Railroad Retirement Board benefit check will include all premiums due from your enrollment

effective date up to the point withholding begins. If Social Security/the Railroad Retirement Board does not

approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

S7694_2015 E1 App_CC2 Approved 01212015

Page 2 of 4

Medicare Prescription Drug Plan Individual Enrollment Form Page 2

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