Medicare Prescription Payment Plan

In 2025 you won't pay more than $2,000 for out-of-pocket Part D covered drug costs. This is true for all who have Medicare drug coverage, even if you haven't joined the Medicare Prescription Payment Plan. The Medicare Prescription Payment Plan simply spreads your costs during the year. Your monthly bill will be based on what you would have paid for any prescriptions you get, plus your previous month's balance, divided by the number of months left in the plan year.

Members who get their drugs from a specialty or mail order pharmacy can still join the Medicare Prescription Payment Plan.

Yes, your payments could change each month if you fill a new prescription. They could also change if you refill a current prescription. This is because the new out-of-pocket drug costs will be added to your monthly payment. And there will be fewer months in the year to disperse the rest of your payments.

For detailed examples and more information about the program, please review our fact sheets:

• Medicare Prescription Payment Plan Fact Sheet – English (PDF)
• Medicare Prescription Payment Plan Fact Sheet – En Español (Spanish) (PDF)

Requests made for the upcoming plan year (or in advance of a new plan enrollment with a starting date during a plan year) your application will be processed within 10 calendar days of receipt. Or, it will be processed the number of calendar days before the plan enrollment starts – whichever time period is shorter. You will be alerted if you are approved or denied electronically and/or by mail.

If we need more information to process your request, you will receive notice from your Part D plan within the same timeframes stated above.

Note: If you request to opt-in to the Medicare Prescription Payment Plan during the plan year, your request will be processed within 24 hours. If more information is needed to process the request, your plan will make efforts to collect the needed information.

If cost sharing was paid to the pharmacy before your election request was received, there are certain conditions where your request can be processed faster and/or after the fact. These include:

• If you believe that any delay in filling the prescription(s) due to the 24 hour processing timeframe may jeopardize your:
  • Life
  • Health
  • Ability to regain maximum function
• If you request retroactive election within 72 hours of the date and time the urgent claim(s) were processed.

Once your Medicare Prescription Payment Plan election has been approved, your plan processes the reimbursement for all cost sharing paid for the urgent prescription(s). Plus, the Payment Plan reimburses any covered Part D prescriptions filled between the date the urgent claim(s) were processed and the date that your election is effective within 45 calendar days of the election date.

If your plan decides that you did not request retroactive election within the required timeframe, you will be alerted of that decision.

• After you opt-in to the program, you will be required to make monthly payments.
• You'll get an itemized invoice each month that details your out-of-pocket cost.
• Any past due balances from prior monthly bills will also be included in your billing statement.
• It is important to make payments timely as your participation in the Medicare Prescription Payment Plan could be terminated if payments are not received within two months of their due date

• You can pay via check, electronic funds transfer or credit card.
• You can also set up monthly recurring payments based on the amounts owed.
• It is important to make timely payments. Your Medicare Prescription Payment Plan terminates if payments are not received within two (2) months of their due date.

• Any past due balances from prior monthly bills are added to your billing statement.
• As stated, it is important to make timely payments. Your Medicare Prescription Payment Plan terminates if payments are not received within two (2) months of their due date.

It depends on your situation. Remember, this payment option might help you manage your monthly expenses, but it doesn't save you money or lower your drug costs. You're most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year (like before September), gives you more months to spread out your drug costs. Go to the Medicare Prescription Payment Plan website to answer a few questions, and find out if you're likely to benefit from this payment option.

The Medicare Prescription Payment Plan option might not be the best choice for you if:

• You can afford to pay your drug costs no matter what month they happen.
• Your yearly drug costs are low.
• Your drug costs are the same each month.
• You’re thinking about signing up for the payment option late in the calendar year (after September).
• You don’t want to change how you pay for your medications.
• You get or are able to get Extra Help from Medicare (see description and link at the end of this section).
• You get or are able to get a Medicare Savings Program (see description and at the end of this section).
• You get help paying for your medications using other means (e.g. A State Pharmaceutical Assistance Program (SPAP) or a charity. (See description and link at the end of this section.)

• Your health or drug plan: Visit our Medicare Prescription Payment Plan Portal or call 1-833-750-9969 TTY 800-726-3231 which is available 24 hours a day, 7 days a week to get more information.
• Medicare: Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
• State Health Insurance Assistance Program (SHIP): Visit the SHIP website to get the phone number for your local SHIP and get free, customized health insurance advice.

You can begin to sign up for the Medicare Prescription Payment Plan starting on October 15th, 2024. Visit our Medicare Prescription Payment Plan Portal or call 1-833-750-9969 TTY 1-800-726-3231 which is available 24 hours a day, 7 days a week to enroll in this payment option. If you have an urgent need to pick up a prescription, the fastest way to use this payment option is to call your plan.

You can also mail your request to us using this Participation Request form (PDF).

Your payment might have changed if you filled a new prescription. Or, it might have changed if you refilled a current prescription. This is because the new out-of-pocket drug costs are added to your monthly payment. And there will be fewer months in the year to disperse the rest of your payments.

You may opt-out of the program if you no longer want to be enrolled. Visit our Medicare Prescription Payment Plan Portal or call 1-833-750-9969 TTY 800-726-3231 which is available 24 hours a day, 7 days a week.

Note: If you owe a balance, you still need to pay it! Even though you're no longer in the Payment Plan program you must pay the balance you owe. Don't forget, once you leave the program, you will pay the pharmacy directly for new out-of-pocket drug costs.

Write: Appeals & Grievances
Medicare Operations
P.O. Box 10450
Van Nuys, CA 91410-0450

Fax: 1-844-273-2671

Please be sure to include your Member ID to ensure timely review.

If you have any other feedback or concerns, or if you feel the plan has not addressed your issue, please call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users can call 1-877-486-2048.

Yes, there are many programs that can help with drug costs. They include:

• Extra Help: The Extra Help program helps people who have modest income and resources to pay Medicare prescription drug program costs. Costs such as:
  • Premiums
  • Deductibles
  • Prescription cost shares

You may qualify for Extra Help based on your income and resources. Beginning in 2024, the program expanded to cover more drug for people with modest resources – those who earn less than 150% of the federal poverty level.

To find out if you qualify for Extra Help, call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778) Monday through Friday, between 8:00 a.m. and 7:00 p.m. local time. You can also apply at your local Social Security Office or online through the Social Security Administration.

If you are able to receive Extra Help, you may find that it is more useful than joining the Medicare Prescription Payment Plan.

• Medicare Savings Programs: These state-run programs might help you pay some or all of your Medicare:
  • Premiums
    
  • Deductibles
  • Copayments
  • Coinsurance

Visit the Medicare Savings Program website to learn more.

• State Pharmaceutical Assistance Programs (SPAPs): These programs might include coverage for your Medicare drug plan premiums and/or cost sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Visit the SPAP website to learn more.

• Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs): These programs are from drug manufacturers to help lower drugs costs for people with Medicare. Visit the PAP website to learn more.