Most of our Medicare Advantage plans include prescription drug coverage. You don't need to fill out a separate auto pay form in that case.

But there are occasions when you need just prescription drug coverage. If you've chosen one of our Part D plans—Prescription Blue PDP Select, Premium or Preferred—and you want to set up auto pay, you can use this form.

Authorization Agreement for Automatic Withdrawal PDP (PDF)

Mail to:

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Prescription Blue PDP
P.O. Box 44256
Detroit, MI 48244-0256
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Fax: 1-866-533-5810