Exhibit 2_Election Request - Track Change

Exhibit 2: Medicare Prescription Payment Plan Participation Request Form
[Instructions: The ‘Medicare Prescription Payment Plan Participation Request Form’ lets a beneficiary notify
the Part D sponsor that they would like to participate in the payment option.
This model form satisfies the requirement for Part D sponsors to provide Part D enrollees with an election
request form to participate in the Medicare Prescription Payment Plan and meets all the communication
requirements outlined at 42 CFR § 423.137(d). Plan sponsors may add their logos to brand this document.
If a Part D sponsor gets a form that it is not complete, the sponsor must contact the individual to ask for more
documentation. Part D sponsors may consider a form complete if it has the enrollee’s name, Medicare number,
and has been signed by the enrollee or their authorized representative. Part D sponsors may also add a field
for plan-specific beneficiary identification numbers to assist with plan processing of enrollment election
requests.
Italicized blue text in square brackets is information for the plans and shouldn’t be included in the request form.
Non-italicized blue text in square brackets may be inserted or used as replacement text in the request form. Use
it as applicable.]

Medicare Prescription Payment Plan
participation request form

The Medicare Prescription Payment Plan is a payment option that works with your current drug coverage to
help you manage your out-of-pocket costs for drugs covered by your plan by spreading them across the calendar
year (January-December). This payment option may might help you manage your expenses, but it doesn’t
save you money or lower your drug costs.
This payment option may 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.
FIRST name:

Complete all fields unless marked optional
LAST name:

MIDDLE initial (optional):

Medicare Number: _ _ _ _ - _ _ _ - _ _ _ _
Birth date: (MM/DD/YYYY)
Phone number:
(_____/_____/______)
(
)
Permanent residence street address (don’t enter a P.O. Box unless you’re experiencing homelessness):
City:

County (optional):

State:

ZIP code:

Mailing address, if different from your permanent address (P.O. Box allowed):
Address:
City:
State:
ZIP code:
[Plan may include a field for enrollees to indicate whether they are requesting participation to begin
immediately (e.g., when submitting election requests late in the year for participation during the current plan
year), or in the upcoming plan year (e.g., when submitting election requests late in the year for participation
during the subsequent plan year). This field may be beneficial to plan sponsors when election requests are
received during or after the annual election period.]
I want to participate in the Medicare Prescription Payment Plan for the:

⎕ Current Plan Year ⎕ Upcoming Plan Year

Formatted: Font: (Default) Times New Roman,
Ligatures: None

Read and sign below
• I understand this form is a request to participate in the Medicare Prescription Payment Plan. [Plan Name] 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 (insert if the terms and conditions are included with this form)].
• [Plan Name] 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.
• I understand that if I stay in the same health or drug plan, [Plan Name] will automatically renew my
participation in the Medicare Prescription Payment Plan at the beginning of each calendar year, unless I
contact [Plan Name] to opt out.
Signature:

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:
Phone number: (

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

Relationship to participant:

How to submit this form
[Plan may insert their instructions for submitting the participation request online, over the phone, or by mail.]
Submit your completed form to:
[Plan Name]
[Plan address]
[Plan address]
[Plan address]
[Plan fax number if applicable]
[Plan email if plan chooses to accept forms via email]
You can also complete the participation request form online at [website link], or call us at [phone number] to
submit your request via telephone.
If you have questions or need help completing this form, call us at [phone number], [days and hours of
operation]. TTY users can call [TTY number].
[Plans can insert their Medicare Prescription Payment Plans terms and conditions on the back of this form or
attach them separately.]