Terms & Conditions
Effective Date: October 1, 2020
This User Agreement ("Agreement") is entered into by and between Shared Health (“SH”) and you, the user (“you“, ”your“, or ”user“), and governs your use of SharedHealth.com (the “Website”).
BY USING THE WEBSITE OR THE SERVICES AVAILABLE ON THIS WEBSITE, YOU AGREE TO THE TERMS OF THIS AGREEMENT JUST AS IF YOU HAD SIGNED THE AGREEMENT. IF YOU DO NOT AGREE TO BE BOUND BY THIS AGREEMENT, YOU MAY NOT ACCESS THIS WEBSITE OR USE ANY OF THE SERVICES THROUGH THIS WEBSITE.
The Website Does Not Provide Medical Advice
The Information on the Website is for informational purposes only. This Website and the Information on it is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Website.
If you think you may have a medical emergency, call your doctor or 911 immediately.
You must be at least of the age of legal majority where you live (which is currently 18 or 19 years old in most states) to use the Website, or you must be at least 13 years old and have the permission of your parent or guardian who must agree to these terms on your behalf. If you have agreed to allow your minor child or a child for whom you are legal guardian (“Minor”) age 13 or over to access the Website or any of the services or Information (as defined below) offered or through the site, you agree that you shall be solely responsible for: (a) the on-line conduct of such Minor; (b) monitoring such Minor’s access to and use of the Website; and (c) the consequences of any use of the Website by such Minor.
Shared Health Dual Plus is an (HMO D-SNP)SM plan and Shared Health Dual Freedom is a (PPO D-SNP)SM plan with a Medicare contract and a contract with the Mississippi Division of Medicaid.
1. License.
SHI hereby grants you a limited, non-exclusive, non-assignable and non-transferable license to access and use the on-line services available on the Website, subject to the terms of this Agreement. All other rights are reserved.
2. Access.
Certain restricted sections of the Website may require you to register on the Website. You must provide SHI with current, accurate, and complete information. Your registration must be done using your real name. If SHI at any time discovers any error or omission in the Information that you provide, SHI may, at its option, terminate the right to access and use the password protected sections of the Website by any user. You may be asked to accept additional terms and conditions prior to enrolling in or using certain restricted services offered through the Website. SHI does not permit (a) any other person using the registered sections under your name; or (b) access through a single name being made available to multiple users on a network. You are responsible for preventing such unauthorized use.
If you learn or suspect that your user name or login password has been disclosed or otherwise made known to any person other than yourself, you agree to immediately notify SHI via e-mail or in writing within twenty-four (24) hours of discovering such fact. Upon receiving such notice, SHI will assign a new password to you within a reasonable period of time.
3. Physician, Practice Group or Agency Access.
Certain services offered through the Website will be accessed and used by physicians, practice groups or authorized agents of SHI and authorized members of their staff. If you are a physician or agent, or a physician’s, practice group’s or an agent’s authorized representative, it is your sole responsibility to identify members of your staff who should be permitted to access and use the Website, and to authorize, monitor and control access to and use of the Website by your staff members. You are responsible for the acts or omissions by your personnel’s use of SharedHealth.com, and for any damages incurred by you as a result thereof.
4. Information.
A. The term “Information” shall mean all content, data and the related subscriptions, products, services and information obtained through the Website. SHI has entered into agreements with certain third-parties whereby SHI may display information, products, goods, or services offered by the third-parties or may provide links from the Website to third-party web sites (the foregoing third-party providers are collectively referred to as “Third-Party Providers”). The term “Information” also refers to Information which is offered by Third-Party Providers. Although SHI may facilitate services and the use of Information from Third-Party Providers, there is no legal affiliation between SHI and such Third-Party Providers.
B. SHI may point or link to other sites maintained by third parties that may be of interest to you. SHI provides such linking functions only as a service to you. SHI does not guarantee that a link will be provided to enable every user to reach their intended party(ies) including, but not limited to physician offices and health plan benefit offices.
C. The Website may enable certain users to transmit, store and receive certain confidential information about members or subscribers (collectively, “Member Information”). State or federal laws, as well as ethical or licensure requirements of the medical profession, may impose obligations with respect to member confidentiality that limit the ability of certain persons to make use of certain services or to transmit certain Information to third parties. You represent and warrant that you will, at all times, comply with all applicable laws that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of Member Information, and to cause all persons or entities under your direction or control to comply with such laws. You are solely responsible for obtaining and maintaining all consents and all other legally necessary consents or permissions required or advisable to disclose, process, retrieve, transmit, and view the Member Information you transmit, store or receive in connection this Website. You agree that SHI, our licensors, and all other persons or entities involved in the operation of, or services provided through, the Website, have the right to monitor, retrieve, store and use Member Information as necessary to provide such operation or services, and are acting on your behalf in transmitting Member Information. WE CANNOT AND DO NOT ASSUME ANY RESPONSIBILITY FOR YOUR USE OR MISUSE OF MEMBER INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED OR RECEIVED USING THE WEBSITE OR THE SERVICES.
5. Ownership.
The Information found on the Website is the property of SHI or its licensors or Third-Party Providers and is protected under applicable copyrights, trademarks, and other proprietary and intellectual property rights. The logos, page headers, custom graphics, buttons, and other icons contain or are proprietary service marks, trademarks, or service marks of SH-MS (collectively, “Trademarks”). Nothing in this Agreement shall be construed as transferring or assigning any ownership rights to you or any other person or entity in the Information or Trademarks.
6. Restrictions.
Only personal use of the Information is permitted, which means that you may access, download or print such Information for your personal, non-commercial use only. You agree not to change or delete any copyright or proprietary notice from Information downloaded from this Website, create compilations or derivative works of any Information, or use the Website or Information in any manner that may infringe any copyright or intellectual property right. You may not copy, republish, display, resell, redistribute, broadcast or transmit, rent, lease, loan, or otherwise transfer the Information or Trademarks or use the Information in a searchable, machine-readable database or file. You agree to use the Website and the Information for lawful purposes only. You agree not to post or transmit any information through the Website which (1) infringes the rights of others or violates their privacy or publicity rights, (2) is unlawful, threatening, abusive, defamatory, libelous, vulgar, obscene, profane, indecent or otherwise objectionable, or (3) is protected by copyright, trademark or other proprietary right without the express permission of the owner of such right. You may only access the Website in a manner that complies with all applicable laws.
7. Submissions.
If you send us suggestions, ideas, notes, computer programs, data, drawings, concepts or other information of any kind (collectively, “Ideas”), the Ideas shall be licensed to SHI. Except as set forth in our Privacy Policy, none of the Ideas shall be subject to any obligation of confidence on the part of SHI and SHI shall not be liable for any use or disclosure of any Ideas. Without limitation of the foregoing, SHI shall be entitled to unrestricted use, not inconsistent with our Privacy Policy, of the Ideas for any purpose whatsoever, without compensation to the provider of the Ideas. Unless otherwise provided, you hereby grant to SHI a worldwide, royalty-free, perpetual, irrevocable, non-exclusive right and license to use, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, perform and display any Idea and to incorporate it in other works in any form, media or technology now known or later developed, except to the extent any of the foregoing would be inconsistent with the Privacy Policy of SHI.
8. Links.
Websites for which SHI provides direct links are separate websites independent of the Website, and they may not follow the same privacy guidelines set forth here. SHI assumes no responsibility or control over the acts or the privacy policies of the third party websites to which SHI provides direct links. We suggest that you contact the appropriate controlling authorities of these sites or review their privacy policy.
You may not create a link to our Website without our prior permission.
9. Changes to Website.
SHI reserves the right at any time and without notice to modify the Website. Such modifications may include, without limitation, changes in services, implementation of user priorities or rules, and discontinuance of functional aspects of the Website. SHI may also add, withdraw or modify Information within the Website or services or products provided throughout the Website at any time in its sole discretion or cancel any link to a third-party website.
10. Monitoring.
You acknowledge that SHI reserves the right to monitor any and all Information or transmissions sent or received through the Website. SHI, at its sole discretion and without further notice to you, may (but is not obligated to) review, censor or prohibit the transmissions or receipt of any Information or transmission which SHI deems as inappropriate or as violating any term or condition of this Agreement. During monitoring, Information or transmission may be examined, recorded and copied to facilitate such monitoring. Use of information associated with monitoring the Website is subject to SHI’s Privacy Policy.
We reserve the right to investigate complaints or reported violations of this Agreement and to take any action we deem appropriate, including but not limited to reporting any suspected unlawful activity to law enforcement officials, regulators, or other third parties and disclosing any information necessary or appropriate to such persons or entities relating to your profile, email addresses, usage history, posted materials, IP addresses and traffic information. We may terminate your use of the Website at any time.
11. Equipment and Operation.
You shall provide and maintain all software, computer hardware, internet connection and other equipment and services necessary to access the Website, and the costs of any such equipment and/or connections or use, including any applicable taxes, shall be borne solely by you.
12. Disclaimer of Warranties.
IN USING THE WEBSITE, YOU ACKNOWLEDGE THAT SOME OF THE INFORMATION PROVIDED THROUGH THE WEBSITE ORIGINATES FROM SOURCES WHICH ARE BEYOND THE CONTROL OF SHI. YOU RECOGNIZE THAT INACCURACIES MAY OCCUR, AND SHI AND ITS LICENSORS AND THIRD-PARTY PROVIDERS DO NOT WARRANT THE ACCURACY OR SUITABILITY OF THE INFORMATION. YOU AGREE THAT THE INFORMATION AND SERVICES AVAILABLE THROUGH THE WEBSITE ARE PROVIDED TO YOU ON AN “AS IS” BASIS. SHI AND ITS LICENSORS AND THIRD-PARTY PROVIDERS EXPRESSLY DISCLAIM ANY AND ALL WARRANTIES, WHETHER EXPRESS, ORAL, IMPLIED, STATUTORY OR OTHERWISE, INCLUDING ANY IMPLIED WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE OR APPLICATION AND ANY IMPLIED WARRANTY OF MERCHANTABILITY, ANY WARRANTIES ARISING BY VIRTUE OF CUSTOM OF TRADE OR COURSE OF DEALING AND ANY IMPLIED WARRANTIES OF TITLE OR NON-INFRINGEMENT OR ADEQUACY TO PRODUCE ANY PARTICULAR RESULT. SHI DOES NOT WARRANT THAT THIS WEBSITE IS FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS.
YOU ACKNOWLEDGE AND AGREE THAT THE INFORMATION AND SERVICES AVAILABLE THROUGH THE WEBSITE ARE NOT INTENDED TO DIAGNOSE, TREAT, CURE OR PREVENT ANY DISEASE. THE WEBSITE DOES NOT CONTAIN ALL MEDICAL INFORMATION THAT MAY BE RELEVANT AND SHOULD NOT BE USED AS A SUBSTITUTE FOR SEEKING PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS, TREATMENT OR CARE. ALL SPECIFIC MEDICAL QUESTIONS YOU HAVE ABOUT A MEDICAL CONDITION, TREATMENT, CARE OR DIAGNOSIS SHOULD BE PRESENTED TO YOUR OWN PROFESSIONAL HEALTH CARE PROVIDER.
SOME STATES DO NOT ALLOW CERTAIN LIMITATIONS ON IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, THE DURATION OF EFFECTIVE WARRANTIES AND/OR THEIR DISCLAIMERS, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU. THIS WARRANTY GIVES YOU SPECIFIC LEGAL RIGHTS, AND YOU MAY ALSO HAVE OTHER RIGHTS THAT VARY FROM STATE-TO-STATE.
Neither SHI nor any of its licensors, licensees and Third-Party Providers shall be liable for any loss or liability resulting from your inability to access the Website or delays or interruptions due to system failures, date-data processing failures, internet problems, weather, strikes, walkouts, fire, acts of God, riots, armed conflicts, acts of war, acts of terrorism or other like causes.
13. Limitation of Liability.
TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT SHALL SHI OR ITS SUPPLIERS, VENDORS OR THIRD PARTY PROVIDERS BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE,INCIDENTAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, OR ANY DAMAGES WHATSOEVER, RESULTING FROM THE USE OF THE WEBSITE OR ANY INFORMATION INCLUDING, WITHOUT LIMITATION, ANY LOSS OF USE, LOSS OF DATA, LOSS OF PROFITS, BUSINESS INTERUPTION, LITIGATION, OR ANY OTHER PECUNIARY LOSS, WHETHER BASED ON BREACH OF CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY OR OTHERWISE, ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE OR PERFORMANCE OF THIS WEBSITE, THE DELAY OR INABILITY TO USE THIS WEBSITE, OR WITH THE INFORMATION, SERVICES, PRODUCTS, MATERIALS OR OTHER RESOURCES PROVIDED HEREIN, OR THE FAILURE TO MAKE AVAILABLE ANY INFORMATION, SERVICES, PRODUCTS, MATERIALS OR OTHER RESOURCES, CONTAINED ON OR ACCESIBLE THROUGH THIS WEBSITE, EVEN IF ADVISED OF THE POSSIBILTY OF SUCH DAMAGES. YOU ACKNOWLEDGE AND AGREE THAT THE LIMITATIONS SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THIS AGREEMENT AND THE WEBSITE WOULD NOT BE PROVIDED TO YOU ABSENT SUCH LIMITATIONS.
SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, SO THE ABOVE LIMITATION OR EXCLUSION MAY NOT APPLY TO YOU. THIS CLAUSE GIVES YOU SPECIFIC LEGAL RIGHTS, AND YOU MAY ALSO HAVE OTHER RIGHTS THAT VARY FROM STATE TO STATE.
14. Indemnification.
YOU AGREE TO RELEASE, INDEMNIFY AND HOLD HARMLESS SH-MS, ITS LICENSORS, AND THIRD-PARTY PROVIDERS (INCLUDING THEIR OFFICERS, DIRECTORS, EMPLOYEES, AFFILIATES, AGENTS, REPRESENTATIVES OR CONTRACTORS) FROM AND AGAINST ALL CLAIMS, DAMAGES, LAWSUITS, JUDGMENTS AND EXPENSES (INCLUDING REASONABLE ATTORNEY’S FEES) RESULTING FROM ANY CLAIM BROUGHT BY ANY PERSON ARISING FROM OR RELATING TO YOUR ACCESS OR USE OF THE WEBSITE, AND THE INFORMATION, SERVICES AND/OR PRODUCTS OBTAINED THROUGH OR PROVIDED BY THE WEBSITE OR YOUR POSTING ANY CONTENT ON THE WEBSITE.
15. Privacy.
You hereby acknowledge having read and accept and agree to all terms and conditions of SHI’S Privacy Policy, which are hereby incorporated in this Agreement.
16. No Conflicting Terms.
If there is any conflict between this Agreement and any other documents regarding the subject matter of this Agreement or the services, products or Information you access, acquire or receive through the Website, then the provisions of this Agreement shall govern, whether such other documents are prior to or subsequent to this Agreement, or are signed or acknowledged by any director, officer, employee, representative or agent of SHI.
17. Attorney’s Fees.
Should litigation, arbitration or other legal action arise from this Agreement, the prevailing party shall be entitled to recover from the non-prevailing party, in addition to all sums to which it is entitled or any other relief, at law or in equity, reasonable attorney’s fees and costs of litigation.
18. Governing Law; Venue.
This Agreement shall be governed by the laws of the State of Tennessee excluding any rule or principle that would refer to and apply the substantive law of another state or jurisdiction. Any such claim or cause of action may only be brought in the state or federal courts located in Chattanooga, Hamilton County, Tennessee and you agree to submit to the exclusive personal jurisdiction of such courts. You agree to waive any objection that the state or federal courts of Tennessee are an inconvenient forum.
19. Waiver.
SHI’s failure to insist upon strict enforcement of any provision of the terms and conditions of this Agreement shall not be construed as a waiver of any such provision or right. Any waiver by SHI of any right or provision herein shall only be by a writing signed by an authorized officer of SHI.
20. Assignment.
You may not assign any of your rights, obligations or privileges here under without the prior written consent of SHI. Any assignment other than as provided for in this Section shall be null and void, ab initio.
21. Severability.
If any provision of this Agreement is found to be unlawful or unenforceable in any respect, the court shall reform such provision so as to render it enforceable or, if it is not possible to reform such provision so as to make in enforceable, then delete such provision. As so reformed or modified, the court shall fully enforce this Agreement.
22. Entire Agreement.
THIS AGREEMENT, ALONG WITH THE SH PRIVACY POLICY, CONSTITUTES THE ENTIRE AGREEMENT BETWEEN THE PARTIES WITH RESPECT TO THE SUBJECT MATTER ADDRESSED HEREIN, AND NO OTHER AGREEMENT, WRITTEN OR ORAL, EXISTS BETWEEN YOU AND SH IN THAT REGARD.
23. Modification to this Agreement.
SHI may modify this Agreement at any time, without notice to you, and such modifications shall be effective immediately upon posting of the modified terms and conditions. Accordingly, you agree to review the terms and conditions periodically, and your continued use of this Website shall be deemed your acceptance of the modified terms and conditions.
24. Child Online Protection Act Notification.
Pursuant to 47 U.S.C. Section 230 (d) as amended, SHI hereby notifies you that parental control protections (such as computer hardware, software, or filtering services) are commercially available that may assist you in limiting access to material that is harmful to minors. Information identifying current providers of such protections is available at OnGuard Online, available at https://www.consumer.ftc.gov/features/feature-0038-onguardonline. Please note that SHI does not endorse any of the products or services offered at such site.
25. Notice and Procedure for Copyright Infringement Claim.
SHI shall respond to notices of alleged infringement that comply with the Digital Millennium Copyright Act and other claims of infringement of intellectual property rights or of libel, slander or invasion of privacy, which response may include removing or disabling access to Information claimed to be the subject of infringing activity or other claims. If you believe that your work has been copied in a way that constitutes copyright infringement, or your intellectual property rights have been otherwise violated, or that you have been libeled, slandered or your privacy invaded, please advise SHI at Shared Health, Inc., ATTN: General Counsel, 1 Cameron Hill Circle, Chattanooga, TN 37402.
You may contact SHI with questions concerning this SHI Agreement.
Fact Sheet
What’s the Medicare Prescription Payment Plan?
The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your outof-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary.
If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). There’s no cost to participate inthe Medicare Prescription Payment Plan.
What to know before participating
How does it work?
When you fill a prescription for a drug covered by Part D, you won’t pay your pharmacy (including mail order and specialty pharmacies). Instead, you’ll get a bill each month from your health or drug plan.
Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. If you want to know what your drug will cost before you take it home, call your plan or ask the pharmacist.
This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. Go to page 5 to learn about Extra Help and other programs that might save you money, if you qualify.
How is my monthly bill calculated?
Your monthly bill is 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 year. All plans use the same formula to calculate your monthly payments.
Your payments might change every month, so you might not know what your exact bill will be ahead of time. Future payments might increase when you fill a new prescription (or refill an existing prescription) because as new out-of-pocket costs get added to your monthly payment, there are fewer months left in the year to spread out your remaining payments.
In a single calendar year (January – December), you’ll never pay more than:
- The total amount you would have paid out of pocket to the pharmacy if you weren’t participating in this payment option.
- The Medicare drug coverage annual out-of-pocket maximum ($2,000 in 2025).
The prescription drug law caps your out-of-pocket drug costs at $2,000 in 2025. This is true for everyone with Medicare drug coverage, even if you don’t participate in the Medicare Prescription Payment Plan.
Will this help me?
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 Medicare.gov/prescription-payment-plan/will-this-help-me to answer a few questions, and find out if you’re likely to benefit from this payment option.
This payment option may not be the best choice for you if:
- Your yearly drug costs are low.
- Your drug costs are the same each month.
- You’re considering signing up for the payment option late in the calendar year (after September).
- You don’t want to change how you pay for your drugs.
- You get or are eligible for Extra Help from Medicare.
- You get or are eligible for a Medicare Savings Program.
- You get help paying for your drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.
Who can help me decide if I should participate?
- Your health or drug plan: Visit your plan’s website, or call your plan to get more information. If you need to pick up a prescription urgently, call your plan to discuss your options.
- Medicare: Visit Medicare.gov/prescription-payment-plan to learn more about this payment option and if it might be a good fit for you.
- State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get the phone number for your local SHIP and get free, personalized health insurance counseling.
How do I sign up?
Visit your health or drug plan’s website, or call your plan to start participating in this payment option:
- In 2024, for 2025: If you want to participate in the Medicare Prescription Payment Plan for 2025, contact your plan now. Your participation will start January 1, 2025.
- During 2025: Starting January 1, 2025, you can contact your plan to start participating in the Medicare Prescription Payment Plan anytime during the calendar year.
Remember, this payment option may not be the best choice for you if you sign up late in the calendar year (after September). This is because as new out-of-pocket drug costs are added to your monthly payment, there are fewer months left in the year to spread out your payments.
What to know if I’m participating
What happens after I sign up?
Once your health or drug plan reviews your participation request, they’ll send you aletter confirming your participation in the Medicare Prescription Payment Plan. Then:
- When you get a prescription for a drug covered by Part D, your plan will automatically let the pharmacy know that you’re participating in this payment option, and you won’t pay the pharmacy for the prescription. Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. If you want to know what your drug will cost before you take it home, call your plan or ask the pharmacist.
- Each month, your plan will send you a bill with the amount you owe for your prescriptions, when it’s due, and information on how to make a payment. You’ll get a separate bill for your monthly plan premium (if you have one).
How do I pay my bill?
After your health or drug plan approves your participation in the Medicare Prescription Payment Plan, you’ll get a letter from your plan with information about how to pay your bill.
What happens if I don’t pay my bill?
You’ll get a reminder from your health or drug plan if you miss a payment. If you don’t pay your bill by the date listed in that reminder, you’ll be removed from the Medicare Prescription Payment Plan. You’re required to pay the amount you owe, but you won’t pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly. If you’re removed from the Medicare Prescription Payment Plan, you’ll still be enrolled in your Medicare health or drug plan.
Always pay your health or drug plan monthly premium first (if you have one), so you don’t lose your drug coverage. If you’re concerned about paying both your monthly plan premium and Medicare Prescription Payment Plan bills, go to page 5 for information about programs that can help lower your costs.
Call your plan if you think they made a mistake about your Medicare Prescription Payment Plan bill. If you think they made a mistake, you have the right to follow the grievance process found in your Member Handbook or Evidence of Coverage.
How do I leave?
You can leave the Medicare Prescription Payment Plan at any time by contacting your health or drug plan. Leaving won’t affect your Medicare drug coverage and other Medicare benefits. Keep in mind:
- If you still owe a balance, you’re required to pay the amount you owe, even though you’re no longer participating in this payment option.
- You can choose to pay your balance all at once or be billed monthly.
- You’ll pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.
What happens if I change health or drug plans?
If you leave your current plan, or change to a new Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage), your participation in the Medicare Prescription Payment Plan will end.
Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.
What programs can help lower my costs?
If you have limited income and resources, find out if you’re eligible for one of these programs:
- Extra Help: A Medicare program that helps pay your Medicare drug costs. Visit ssa.gov/medicare/part-d-extra-help to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov/ExtraHelp to learn more.
- Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit Medicare.gov/medicare-savings-programs to learn more.
- State Pharmaceutical Assistance Programs (SPAPs): Programs that 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 go.medicare.gov/spap to learn more.
- Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs)): Programs from drug manufacturers to help lower drugs costs for people with Medicare. Visit go.medicare.gov/pap to learn more.
Many people qualify for savings and don’t realize it. Visit Medicare.gov/basics/costs/help, or contact your local Social Security office to learn more. Find your local Social Security office at ssa.gov/locator/.
Where can I get more information?
- Your health or drug plan: Visit your plan’s website, or call your plan to get more information.
- Medicare: Visit Medicare.gov/prescription-payment-plan, 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.
Examples of how a monthly bill is calculated
Example 1:
You take several high-cost drugs that have a total out-of-pocket cost of $500 each month. In January 2025, you join the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
- First, we figure out your “maximum possible payment” for the first month:
$2,000 [annual out-of-pocket maximum]
– $0 [no out-of-pocket costs before using this payment option]
= $2,000
12 [remaining months in the year]
- Then, we figure out what you’ll pay for January:
- Compare your total out-of-pocket costs for January ($500) to the “maximum possible payment” we just calculated: $166.67.
- Your plan will bill you the lesser of the two amounts. So, you’ll pay $166.67 for the month of January.
- You have a remaining balance of $333.33 ($500-$166.67).
For February and the rest of the months left in the year, we calculate your payment differently:
$333.33 [remaining balance] + $500 [new costs]
= $833.33
11 [remaining months in the year]
We’ll calculate your March payment like we did for February:
$757.57 [remaining balance] + $500 [new costs]
= $1,257.57
10 [remaining months in the year]
In April, when you refill your prescriptions again, you’ll reach the annual out-ofpocket maximum for the year ($2,000 in 2025). You’ll continue to pay what you already owe and get your prescription(s), but after April you won’t add any new outof-pocket costs for the rest of the year.
$1,131.81 [remaining balance] + $500 [new costs]
= $1631.81
9 [remaining months in the year]
Even though your payment varies each month, by the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-pocket.
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 1: Start participating in January with high drug costs early in the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $500 | $166.67 | This is when you started participating in this payment option. Remember, your first month’s bill is based on the “maximum possible payment” calculation. We calculate your bill for the rest of the months in the year differently. |
| February | $500 | $75.76 | |
| March | $500 | $125.76 | |
| April | $500 | $181.31 | This month you reached the annual out-of-pocket maximum ($2,000 in 2025). You’ll have no new out-of-pocket drug costs for the rest of the year. |
| May | $0.00 | $181.31 * | *You’ll still get your $500 drugs each month, but because you’ve reached the annual out-of-pocket maximum, you won’t add any new out-of-pocket costs for the rest of the year. You’ll continue to pay what you already owe. |
| June | $0.00 | $181.31 * | |
| July | $0.00 | $181.31 * | |
| August | $0.00 | $181.31 * | |
| September | $0.00 | $181.31 * | |
| October | $0.00 | $181.31 * | |
| November | $0.00 | $181.31 * | |
| December | $0.00 | $181.31 * | |
| Total | $2,000.00 | $2,000.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
If you’re concerned about paying $500 each month from January to April, this payment option will help you manage your costs. If you prefer to pay $500 each month for 4 months and then pay $0 for the rest of the year, this payment option might not be right for you. Contact your health or drug plan for personalized help.
Example 2:
You take several drugs that have a total out-of-pocket cost of $80 each month. In January 2025, you join the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
- First, we figure out your “maximum possible payment” for the first month:
$2,000 [annual out-of-pocket maximum]
– $0 [no out-of-pocket costs before using this payment option]
= $2,000
12 [remaining months in the year]
- Then, we figure out what you’ll pay for January:
- Compare your total out-of-pocket costs for January ($80) to the “maximum possible payment” we just calculated: $166.67.
- Your plan will bill you the lesser of the two amounts. So, you’ll pay $80 for the month of January.
- You have a remaining balance of $0.
For February and the rest of the months left in the year, we calculate your payment differently:
$0 [remaining balance] + $80 [new costs] = $80
11 [remaining months in the year]
We’ll calculate your March payment like we did for February:
$72.73 [remaining balance] + $80 [new costs] = $152.73
10 [remaining months in the year]
Even though your payment varies each month, by the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-pocket.
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 2: Start participating in January with consistent costs throughout the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $80.00 | $80.00 | This is when you started using this payment option. Remember, your first month’s bill is based on the “maximum possible payment” calculation. We calculate your bill for the rest of the months in the year differently. |
| February | $80.00 | $7.27 | |
| March | $80.00 | $15.27 | |
| April | $80.00 | $24.16 | This month you reached the annual out-of-pocket maximum ($2,000 in 2025). You’ll have no new out-of-pocket drug costs for the rest of the year. |
| May | $80.00 | $34.16 | *You’ll still get your $500 drugs each month, but because you’ve reached the annual out-of-pocket maximum, you won’t add any new out-of-pocket costs for the rest of the year. You’ll continue to pay what you already owe. |
| June | $80.00 | $45.59 | |
| July | $80.00 | $58.93 | |
| August | $80.00 | $74.92 | |
| September | $80.00 | $94.93 | |
| October | $80.00 | $121.59 | |
| November | $80.00 | $161.59 | |
| December | $80.00 | $241.59 | |
| Total | $960.00 | $960.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
Depending on your specific circumstances, you might not benefit from using this payment option due to the higher payments that start in September. Contact your health or drug plan for personalized help.
Example 3:
You pay $4 every month in out-of-pocket costs for a prescription you use regularly. In April 2025, you need a new one-time prescription that costs $613, so your total out-of-pocket costs in April are $617. That same month, before you fill your prescriptions, you decide to participate in the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
- First, we figure out your “maximum possible payment” for the first month:
$2,000 [annual out-of-pocket maximum]
– $12 [your out-of-pocket costs before using this payment option]
= $1,988
9 [remaining months in the year]
- Then, we figure out what you’ll pay for April:
- Compare your total out-of-pocket costs for April ($617) to the “maximum possible payment” we just calculated: $220.89.
- Your plan will bill you the lesser of the two amounts. So, you’ll pay $220.89 for the month of April.
- You have a remaining balance of $396.11 ($617 – $220.89).
For May and the rest of the months left in the year, we calculate your payment differently:
$396.11 [remaining balance] + $4 [new costs] = $400.11
8 [remaining months in the year]
Your payments will vary throughout the year. That’s because you’re adding drug costs during the year, but you have fewer months left in the year to spread your payments across.
By the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-pocket.
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 3: Start participating in April with varying costs throughout the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $4.00 | $4.00* | *You made these payments directly to the pharmacy before you started participating in the Medicare Prescription Payment Plan. |
| February | $4.00 | $4.00* | |
| March | $4.00 | $4.00* | |
| April | $617.00 | $220.89 | This is when you started using this payment option. Remember, your first month’s bill is based on the “maximum possible payment” calculation. We calculate your bill for the rest of the months in the year differently. |
| May | $4.00 | $50.01 | *You’ll still get your $500 drugs each month, but because you’ve reached the annual out-of-pocket maximum, you won’t add any new out-of-pocket costs for the rest of the year. You’ll continue to pay what you already owe. |
| June | $4.00 | $50.59 | |
| July | $124.00 | $71.25 | This month, you need a drug that’s $120, in addition to your $4 drug. Following the same formula we used in May, your payments increase because you’re adding drug costs during the year, but you have fewer months left in the year to spread your payments across. |
| August | $4.00 | $72.05 | |
| September | $4.00 | $73.05 | |
| October | $124.00 | $114.39 | This month, you need a drug that’s $120, in addition to your $4 drug. Following the same formula we used in May, your payments increase because you’re addingdrug costs during the year, but you have fewer months left in the year to spread your payments across. |
| November | $4.00 | $116.39 | |
| December | $4.00 | $120.38 | |
| Total | $901.00 | $901.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
If you’re concerned about paying $617 in April, this payment option will help you spread your costs across monthly payments that vary throughout the year. If you’re concerned about higher payments later in the year, this payment option might not be right for you. Contact your health or drug plan for personalized help.
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