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Member Handbook (EOC)

Select your health plan to view the Member Handbook (EOC)

Medi-Cal

Public program for low income people

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CommuniCare Advantage

Medicare and Medi-Cal benefits

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Community y Más

Medicare plan for chronic care needs

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Medicare Prescription Payment Plan Program

Resources for Members

Medicare Prescription Payment Plan Participation Request Form

Complete all fields unless marked optional
* Required Field

10 digits phone number

2 letters state

5 digits zip code

2 letters state

5 digits zip code

Do you get help paying your prescription drug costs from a program like Medicare’s Extra Help, a State Pharmaceutical Assistance Program (SPAP), Indian Health Services, or other health insurance?

Acknowledgement

  • I understand this form is a request to participate in the Medicare Prescription Payment Plan. Community y Más will contact me if they need more information.
  • I understand that signing this form means that I've read and understood the form.
  • Community y Más 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 the participation form and have documentation of this authority available if Medicare asks for it.

10 digits phone number