NL 00720: Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
TN 2 (09-11)
MPD346 (HC3)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
Based on the information we have (1) (2) due a refund for prescription drug coverage income-related monthly adjustment amounts.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: (Name)
Choice 2: you
Fill-in (2) - Systems Generated
Choice 1: is
Choice 2: are
MPD347 (HC4)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
This payment includes a refund of (1) prescription drug coverage income-related monthly adjustment amount.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name possessive
Choice 2: your
MPD348 (HC5)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check (3) will receive for (4) on or about (5) .
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (3) - Systems Generated
Choice 1: he
Choice 2: she
Choice 3: you
Fill-in (4) - Requested As A Date In Format Shown
Choice 1: MM/CCYY
Fill-in (5) - Requested As A Date In Format Shown
Choice 1: MM/DD/CCYY
MPD349 (HC6)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
The monthly deduction for (1) prescription drug coverage income-related monthly adjustment amount is (2) .
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
MPD350 (HC7)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
We deducted (1) for (2) prescription drug coverage income-related monthly adjustment amount from the check you will receive on or about (3) .
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount
Fill-in (2) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (3) - Requested As A Date In Format Shown
Choice 1: MM/DD/CCYY
MPD351 (HC8)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
We will no longer deduct (1) prescription drug coverage income-related monthly adjustment amount from (2) monthly benefits.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name possessive
Choice 2: your
Fill-in (2) - Systems Generated
Choice 1: his
Choice 2: her
Choice 3: your
MPD352 (HC9)
(Requested/Generated)
Caption: Information About The Prescription Drug Coverage (IRMAA)
We are deducting past-due prescription drug coverage income-related monthly adjustment amounts from (1) check.
Fill-in values:
Fill-in (1) - Systems Generated
Choice 1: Name possessive
Choice 2: your