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This one-time payment can be only used to pay your Medicare Advantage Premiums, please do not use for Medicare Prescription Payment Plan (MPPP) payments. <br /> <br /> <br /> <br /> <a href="#sidePanel" role="button" data-toggle="collapse">Click for more information.</a> <br /> <br /> </div> <div id="sidePanel" class="collapse"> <div class="alert-info-well"> <span style="color: rgb(247, 150, 70);">Need Help?</span><br><span style="font-size: 12px;">You may reach us at (855) 833-3668 (TYY 711). You may email your questions to <a href="/cdn-cgi/l/email-protection" class="__cf_email__" data-cfemail="68250d0c290c1e0b1d1b1c07050d1a1b0d1a1e010b0d280904041f09111b000d09041c0046071a0f">[email protected]</a>.</span><br style="font-size: 12px;"><span style="font-size: 12px;">Hours: October 1 - March 31, seven days a week from 8:00AM - 8:00PM and April 1 through September 30, Monday through Friday from 8:00AM - 8:00PM.</span> </div> </div> <script data-cfasync="false" src="/cdn-cgi/scripts/5c5dd728/cloudflare-static/email-decode.min.js"></script><script type="text/javascript"> //<![CDATA[ Sys.WebForms.PageRequestManager._initialize('ctl00$ctl00$cphBody$cphBodyLeft$ScriptManager1', 'aspnetForm', ['tctl00$ctl00$cphBody$cphBodyLeft$ErrorMessagePanel','','tctl00$ctl00$cphBody$cphBodyLeft$CloudStoreItemsQuantityUpdatePanel','','tctl00$ctl00$cphBody$cphBodyLeft$CartUpdatePanel','','tctl00$ctl00$cphBody$cphBodyLeft$SummaryPanel',''], [], ['ctl00$ctl00$cphBody$cphBodyLeft$selectedItemsCart$Repeater1',''], 90, 'ctl00$ctl00'); //]]> </script> <div id="ctl00_ctl00_cphBody_cphBodyLeft_ErrorMessagePanel"> </div> <div id="ic-error-message"></div> <script type="text/javascript">$(function () { init_client_validate(); });</script><div class="row display-flex"> <div class="col-sm-6 col-xs-12"> <div class="form-group"> <label class="ic-label-required" for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9170">Member ID </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$t_9170" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9170" class="form-control input-block-level ic-type-string ic-field-required" title="" placeholder="Member ID" /> </div> </div><div class="col-sm-6 col-xs-12"> <div class="form-group"> <label class="ic-label-required" for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9165">Subscriber First Name </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$t_9165" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9165" class="form-control input-block-level ic-type-string ic-field-required" title="" placeholder="Subscriber First Name" /> </div> </div><div class="col-sm-6 col-xs-12"> <div class="form-group"> <label class="ic-label-required" for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9166">Subscriber Last Name </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$t_9166" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9166" class="form-control input-block-level ic-type-string ic-field-required" title="" placeholder="Subscriber Last Name" /> </div> </div><div class="col-sm-6 col-xs-12"> <div class="form-group"> <label class="ic-label-required" for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9167">ZIP Code </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$t_9167" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9167" class="form-control ic-type-string ic-field-required" title="" placeholder="ZIP Code" style="width:100px;" /> </div> </div><div class="col-sm-6 col-xs-12"> <div class="form-group"> <label for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9168">Phone Number </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$t_9168" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_t_9168" class="form-control input-block-level ic-type-string" title="" placeholder="Phone Number" /> </div> </div><div class="col-sm-6 col-xs-12"> <div class="form-group"> <label class="ic-label-required" for="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_p_9169">Payment Amount </label><input name="ctl00$ctl00$cphBody$cphBodyLeft$ctl05$p_9169" type="text" id="ctl00_ctl00_cphBody_cphBodyLeft_ctl05_p_9169" class="form-control ic-type-money ic-field-required" title="" placeholder="$0.00" style="width:100px;" /> </div> </div> </div> <div> <div class="button-container" style="padding-top: 30px; padding-left: 0px; padding-right: 0px;"> <a id="ctl00_ctl00_cphBody_cphBodyLeft_ConfirmButton" class="btn btn-primary ic-button ic-button-primary" href="javascript:__doPostBack('ctl00$ctl00$cphBody$cphBodyLeft$ConfirmButton','')"> Confirm Your Information <span class="glyphicon glyphicon-chevron-right"></span> </a>   </div> </td> <td id="right-column" class="col-md-3 hidden-xs hidden-sm"> <div style="max-width: 205px"> <img id="ctl00_ctl00_cphBody_cphBodyRight_imgVisa" src="../images/visa_icon.gif" alt="Visa Accepted" style="border-width:0px;height:24px;margin-bottom:2px" /> <img id="ctl00_ctl00_cphBody_cphBodyRight_imgMasterCard" src="../images/mastercard_icon.gif" alt="MasterCard Accepted" style="border-width:0px;height:24px;margin-bottom:1px" /> <img id="ctl00_ctl00_cphBody_cphBodyRight_imgAmex" src="../images/american_express_icon.gif" alt="American Express Accepted" style="border-width:0px;height:24px;margin-bottom:1px" /> <img id="ctl00_ctl00_cphBody_cphBodyRight_imgDiscover" src="../images/discover_icon.gif" alt="Discover Accepted" style="border-width:0px;height:24px;" /> <img id="ctl00_ctl00_cphBody_cphBodyRight_imgACH" src="images/bankIcon.png" alt="Check Payment Accepted" style="border-width:0px;height:25px;" /> </div> <br /> <br /> <div id="payer-support" style="font-size: 12px !important; width: 185px !important;"> <span style="font-size: 14px; color: rgb(247, 150, 70); --darkreader-inline-color: #b16a2f;" data-darkreader-inline-color=""><strong>Need Help?</strong></span><br><span style="font-size: 14px;"><br></span><span style="font-size: 14px;"><strong>Medicare Advantage</strong></span><br><span style="font-size: 11px;">You may reach us at (855) 833-3668 (TYY 711). You may email your questions to <a href="/cdn-cgi/l/email-protection" class="__cf_email__" data-cfemail="6a220f0b061e023a060b04270f0e2b0e1c291f191e05070f18390f181c03090f2a070d084405180d">[email protected]</a>.<br>Hours: October 1 - March 31, seven days a week from 8:00AM - 8:00PM and April 1 through September 30, Monday through Friday from 8:00AM - 8:00PM.</span><br><span style="font-size: 14px;"><br></span><span style="font-size: 14px;"><strong>Commercial HMO/PPO</strong></span><br><span style="font-size: 11px;">You may reach us at (866) 643-8392. You may email your questions to <a href="/cdn-cgi/l/email-protection" class="__cf_email__" data-cfemail="5f173a3e332b370f333e311d3633333631381f32383d71302d38">[email protected]</a>. </span> </div> </td> </tr> </table> <script data-cfasync="false" src="/cdn-cgi/scripts/5c5dd728/cloudflare-static/email-decode.min.js"></script><script type="text/javascript">pendo.initialize({visitor: {id: '4b1bf863-f861-4abc-9a2a-b98aa06d9ba3-eae72ed0-440a-4bf7-8b6d-bb8df06bb7da638682841619979769',authenticated: 'False',invoice_type: '69',visitor_environment: 'Production'},account: {id: 'Mass General Brigham Health Plan',account_environment: 'Live',Biller_software_partner: 'Neighborhood Health Plan ',Biller_has_autopay: 'True',Biller_has_paperless: 'True',Billertier: '0',CloudStore: 'True',Date_live: '8/15/2017',Multi_user: 'False',vertical: 'Insurance',BID: '1170',State: 'MA'}});</script></form> <div class="ic-footer"> <span> <svg xmlns="http://www.w3.org/2000/svg" width="169" height="24" viewBox="0 0 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