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 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

Permanent residence street address (don’t enter a P.O. Box unless you’re experiencing homelessness):

Mailing address, if different from your permanent address (P.O. Box allowed):

Read and sign below

  • I understand this form is a request to participate in the Medicare Prescription Payment Plan. KeyCare Advantage 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.
  • KeyCare Advantage 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.

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.