CALOPTIMA | Health Plans

Medicare Prescription Payment Plan 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). For help, call us toll-free at 1-877-412-2734 (TTY 711.)

Learn more

Want to opt into the Medicare Prescription Payment Plan?

Fill out the form below:

Complete all fields unless marked optional.

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First Name:

Last Name:

Middle Initial (optional):

Medicare Number:

Birth Date:

Phone Number:

Address:

City:

County:

State:

Zip Code:

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

City:

County:

State:

Zip Code:

Read and Sign below

I understand this form is a request to participate in the Medicare Prescription Payment Plan. CalOptima Health OneCare Flex Plus (HMO D-SNP), a Medicare Medi-Cal 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 fact sheet.

CalOptima Health OneCare Flex Plus 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

Date

I agree that typing my name is my electronic signature. I acknowledge and agree that my electronic signature has the same effect as a handwritten signature. I also confirm that I have the authority to sign on behalf of any entity I represent.

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

Address (Street, City, State, ZIP code):

Phone Number

Relationship to participant:

Call us toll-free at 1-877-412-2734 (TTY 711) to submit your request via telephone. Or fax a paper copy of this form to: 1-714-246-8711.

If you have questions or need help completing this form, call us at 1-877-412-2734 (TTY 711), 24 hours a day, 7 days a week.