Tip for Plan-specific (CMS model template)

Late enrollment penalty: 1% of the national base premium for every month you were without creditable coverage — this penalty is permanent

Tip for Plan-specific (CMS model template)

Use the Medicare.gov Plan Finder to compare plans based on YOUR specific medications and pharmacies

Tip for Plan-specific (CMS model template)

Check the plan's formulary tier for each of your medications — costs can vary dramatically between plans

Medicaremoderate

Medicare Part D Enrollment

Plan-specific (CMS model template) · Part D Plan Sponsors

Enrollment in a Medicare Part D prescription drug plan. Current medication list is the critical input for plan comparison and selection.

Form Details

Total fields: 35
Auto-fillable: 28 (80%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: annual

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Where to Submit This Form

🌐

Medicare.gov Plan Finder (recommended)

https://www.medicare.gov/plan-compare/

Compare and enroll in Part D plans online.

📬

Mail the plan's enrollment form

Each Part D plan provides its own enrollment form on its website or by request.

🏢

Through a licensed insurance agent, SHIP counselor, or at a plan enrollment event

Filing Deadline

Initial Enrollment: 3 months before to 3 months after turning 65. Annual Enrollment: Oct 15 - Dec 7. Special Enrollment: within 63 days of losing other creditable drug coverage.

Required Attachments

📎 Medicare number (from your Medicare card)
📎 Current prescription list for plan comparison
📎 Proof of creditable coverage (if enrolling during SEP to avoid late penalty)

Processing Time

Enrollment processed within 14 days. New coverage starts the first of the month following enrollment (or January 1 during AEP).

What Happens Next

You will receive plan materials including the Evidence of Coverage and formulary. Your new plan card will arrive before your coverage start date.

Tips for This Form

✓ Late enrollment penalty: 1% of the national base premium for every month you were without creditable coverage — this penalty is permanent
✓ Use the Medicare.gov Plan Finder to compare plans based on YOUR specific medications and pharmacies
✓ Check the plan's formulary tier for each of your medications — costs can vary dramatically between plans
✓ If you have employer retiree drug coverage, verify it is 'creditable' before declining it for Part D

More Medicare Forms

Medicare Part B Enrollment

CMS-40B · CMS

Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.

Request for Employment Information

CMS-L564 · CMS

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.

Part A/B Special Enrollment (Exceptional Conditions)

CMS-10797 · CMS

Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.

Part B Immunosuppressive Drug Coverage Enrollment

CMS-10798 · CMS

Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.

Medicare Advantage Enrollment

Plan-specific (CMS model template) · CMS

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Medicare Advantage Disenrollment

CMS model disenrollment form · CMS

Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Part D Plan Sponsors or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.