Medicare Prescription Payment Plan Terms and Conditions
You’ve applied for a Medicare Prescription Payment Plan offered by Shared Health. Shared Health is responsible for:
BY APPLYING FOR AND ENROLLING IN A MEDICARE PRESCRIPTION PAYMENT PLAN THROUGH SHARED HEALTH, I UNDERSTAND AND AGREE TO THE FOLLOWING TERMS AND CONDITIONS:
1. Eligibility
2. Participation Requirements
3. Retroactive Election
4. Payment and Related Terms
5. Cancellation and Termination
6. Nonpayment of Medicare Prescription Payment Plan Monthly Payment
7. Amendments
8. Appeals and Grievances
9. Acceptance of This 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 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:
Who can help me decide if I should participate?
How do I sign up?
Visit your health or drug plan’s website, or call your plan to start participating in this payment option:
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:
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:
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:
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?
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:
$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]
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:
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:
$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]
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:
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:
$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]
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:
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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