Medicare Prescription Drug Plan Individual Enrollment Form Page 3
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8Paying Your Plan Premium
You can pay your monthly plan premium (including any late enrollment penalty you may owe) by mail
or Electronic Funds Transfer (EFT) 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 (Part D-IRMAA), 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
Blue Cross MedicareRx.
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 coinsurance. 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
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. You must continue to pay your Medicare
Part B premium.
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
Saving
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.)
Applicant LAST name:
FIRST name:
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Parent category: Medical