Medicare Prescription Payment Plan

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.

Once you’ve joined the program, we calculate your first month’s bill differently than your bill for the rest of the months in the year:

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.

Once you join the program, we calculate your first month’s bill differently than your bill for the rest of the months in the year:

You pay $4 every month in out-of-pocket costs for a prescription you use on a regular basis.

In April 2025, you need a new one-time prescription that costs $613. Your total out-of-pocket costs in April are $617. That same month, before you fill your prescriptions, you decide to join the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan.

Once you join the program, we calculate your first month’s bill differently than your bill for the rest of the months in the year:

Your payments will vary throughout the year. That’s because you add drug costs during the year, but you have fewer months left in the year to spread your payments across. 

Example 1:

You take several high-cost drugs that have a total out-of-pocket cost of $525 each month.

In January 2026, 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 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:

$2,100 [annual out-of-pocket maximum]

–

$0 [no out-of-pocket costs before using this payment option]

$2,100 ÷ 12 [remaining months in the year] = $175.00 [your “maximum possible payment” for the first month]

Then, we figure out what you’ll pay for January:

• Compare your total out-of-pocket costs for January ($525) to the “maximum possible payment” we just calculated: $175.00.
• Your plan will bill you the lesser of the two amounts. So, you’ll pay $175.00 for the month of January.
• You have a remaining balance of $350.00 ($525-$175).

For February and the rest of the months left in the year, we calculate your payment differently:

$350.00 [remaining balance]

+

$525 [new costs]

$875.00 ÷ 11 [remaining months in the year] = $79.55 [your payment for February]

For March we’ll calculate your payment like we did for February:

$795.45 [remaining balance]

+

$525 [new costs]

$1,320.45 ÷ 10 [remaining months in the year] = $132.05 [your payment for March]

In April, when you refill your prescriptions again, you’ll reach the annual out-of-pocket maximum for the year ($2,100 in 2026).

You’ll continue to pay what you already owe and get your prescription(s), but after April you won’t add any new out-of-pocket costs for the rest of the year.

$1,188.40 [remaining balance]

+

$525 [new costs]

$1,713.40 ÷ 9 [remaining months in the year] = $190.38 [your payment for April and all 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 ($2,100 in 2026).

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:

You take several drugs that have a total out-of-pocket cost of $80 each month.

In January 2026, 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:

$2,100 [annual out-of-pocket maximum]

–

$0 [no out-of-pocket costs before using this payment option]

$2,100 ÷ 12 [remaining months in the year] = $175.00 [your “maximum possible payment” for the first month]

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: $175.00.
• Your plan will bill you the lesser of the two amounts. So, you’ll pay $80.00 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] = $7.27 [your payment for February]

For March we’ll calculate your payment like we did for February:

$72.73 [remaining balance]

+

$80 [new costs]

$152.73 ÷ 10 [remaining months in the year] = $15.27 [your payment for March]

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 ($2,100 in 2026).

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:

You pay $4 every month in out-of-pocket costs for a prescription you use regularly.

In April 2026, 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:

$2,100 [annual out-of-pocket maximum]

–

$12 [no out-of-pocket costs before using this payment option]

$2,088 ÷ 9 [remaining months in the year] = $232.00 [your “maximum possible payment” for the first month]

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: $232.00.
• Your plan will bill you the lesser of the two amounts. So, you’ll pay $232.00 for the month of April.
• You have a remaining balance of $385 ($617 – $232).

For May and the rest of the months left in the year, we calculate your payment differently:

$385 [annual out-of-pocket maximum]

–

$4 [no out-of-pocket costs before using this payment option]

$389 ÷ 8 [remaining months in the year] = $48.63 [your payment in May]

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 ($2,100 in 2026).

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.

Part D enrollees can opt in prior to the start of the plan year or in any month during the plan year. You can do this by using one of these options:

• Complete and submit the online request form.
• Download and mail in the request form.
• Contact us to submit a request by phone.

In 2025, for 2026: If you want to participate in the Medicare Prescription Payment Plan for 2026, contact your plan now. Your participation will start January 1, 2026. If you've already completed an election request this year, your election will be automatically renewed next year.

During 2026: Starting January 1, 2026, you can contact your plan to start participating in the Medicare Prescription Payment Plan anytime during the calendar year.

It depends on your situation. 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 the program if you have high drug costs early in the calendar year. You can start using this payment option at any time in the year. If you start early in the year (like before September), you will have more months to spread out your drug costs. Go to medicare.gov to answer a few questions and find out if you might benefit from this payment option. For more information, review the Medicare Prescription Payment Plan Fact Sheet.

This payment option might 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.

If signing up in 2025 for 2026: Your plan will process your Medicare Prescription Payment election request within 10 days or until 12/31.  If more information is needed, enrollment may be delayed up to 10 days.

During 2026: Plans have 24 hours to review Medicare Prescription Payment Plan election requests.

Once we review your request to join, we’ll send you a letter that confirms you are signed up for the Medicare Prescription Payment Plan. Then:

1. When you get a prescription for a drug covered by Part D, we will automatically let the pharmacy know that you have this payment option. 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, contact us or ask the pharmacist.
   
   
2. Each month, we 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).

Online Member Portal

Once you have been approved to join the Medicare Prescription Payment Plan, you are able to create an account on the online member portal to manage your account. Visit the online member portal to create an account or log in.

Bill Payment

After we process and approve your request to join the Medicare Prescription Payment Plan, you’ll get a letter from us with information about how to pay your bill.

Please note:

• You’ll get a reminder from us 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 program.
• 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 the amount you owe 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.
• Credit card and debit card payments will not be accepted.

Contact us if you think they made a mistake about your Medicare Prescription Payment Plan bill. If you think we made a mistake, you have the right to follow the grievance process or reference your Evidence of Coverage.

You can leave the Medicare Prescription Payment Plan at any time. Just contact us. 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 program.

Your participation in this program will end if you:

• Leave your current plan.
• Change to a new Medicare drug plan.
• Change to a new Medicare health plan with drug coverage (like a Medicare Advantage Plan).

For more information, contact us.

You can submit an urgent request to join this program if you paid your cost share for a certain vital prescription that was filled before we received and processed your request.

An urgent retroactive request to join the program can be processed if all these conditions are met:

• You believe a delay in getting your prescriptions due to the 24-hour turnaround time may seriously jeopardize your life, health, or ability to function; and
• You ask for a retroactive request within 72 hours of the date and time a review and decision was made about covering urgent claim(s). Once you are in the program, we will process the reimbursement for what you paid for the urgent prescription. We also will cover any Part D prescription filled between when a decision about the urgent claim was made and the date the program request started; we’ll do this within 45 calendar days of the day you start the program. 
• If we decide that you did not request to join within the required timeframe, we will promptly notify you. You will get instructions on how to file a grievance. 

To make an urgent request to join the Medicare Prescription Payment Plan, contact us.