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Auto Payments from Bank Acct, SS, RRB

Sign up today for secure automatic payments!

There are two ways you can make automatic payments online for your monthly plan premium and/or your Part D late enrollment penalty (if applicable). Payments can be:

Deducted from your Social Security or Railroad Retirement Board check
Electronically debited from your bank account

To set up automatic deduction for your monthly plan premium and/or your Part D late enrollment penalty (if you pay one) please fill out the secure form below. IMPORTANT: You will no longer receive a monthly bill in the mail when you sign up for automatic payments. To make a one-time payment using a credit card, use our online bill payment service.

* Indicates required

First Name * Last Name * Date of Birth * Generations Advantage Member ID # *

OPTION 1: SOCIAL SECURITY or RAILROAD RETIREMENT BOARD (RRB) Benefit Check— Payment deducted monthly

NOTE: The Social Security or RRB deduction may take two or more months to begin. You will be billed directly by the plan for the months before the Social Security or RRB deduction begins. If your request for Social Security Administration deductions is not approved, you will continue to receive invoices from Martin’s Point Generations Advantage.

OPTION 2: BANK ACCOUNT—Payment electronically debited monthly Checking or Savings? * Checking Savings Bank Name * Routing # * Account # *

By TYPING MY NAME IN THE SIGNATURE FIELD, I authorize Martin’s Point Generations Advantage to charge my monthly premium and/or Part D late enrollment penalty, in addition to any past due amount, to the above bank account. This authorization will remain in force as long as my membership is active in a plan requiring a premium, as long as I have a Part D late enrollment penalty, or until I cancel or change this request. This option will continue even if the monthly payment amount changes. I understand it can take up to 30 days advance notice before changes to this payment option can be made, unless my membership ends and/or payments are no longer due.

Signature *