Prescription Drug Plan Late Enrollment Penalty Inquiry Form
Use this form to ask about a late enrollment penalty related to your prescription drug plan. Please provide as much detail as possible to help us address your inquiry efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Prescription Drug Plan Provider
*
Plan Member ID (if known)
Year or Period of Enrollment
*
How did you learn about your late enrollment penalty?
Please Select
Letter or Notice from Plan
Phone Call from Plan
Online Account or Portal
Customer Service Representative
Other
Please describe your late enrollment penalty inquiry
*
Preferred Contact Method
Email
Phone
Either
Additional Comments or Questions
Submit Inquiry
Should be Empty: