Automatic Payment Forms

Who is this for?

Medicare Help Center | Forms | Automatic Payments Form

If you want to have your Medicare plan payment automatically deducted from your bank each month, use this form to tell us.

Don't want to worry about remembering to pay your bill? Interested in saving a little money on checks and stamps?

Have your monthly payment for your plan automatically deducted from your bank account. It's safe and secure. If you didn't set up Automated Clearing House, or ACH, transfers when you first enrolled, you can do it at any time using these forms. You'll need:

  • Your Blue Cross ID card.
  • Your bank's name.
  • The number of the account you want to use for the payments.
  • Your bank's routing number, shown below.
  • A voided check if you're using a checking account, or if you're using a savings account, a deposit slip  with your account number on it.
It's safe, easy and convenient to auto pay your monthly Medicare plan bill.