Medicare Prescription Payment Plan
Medicare Prescription Payment Plan
WHAT IS 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 out- of-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 in the 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 Verda Healthcare or ask the pharmacist.
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This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. Go to the section below on “What programs can help lower my costs?” to learn about Extra Help and other programs that might save you money, if you qualify. |
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How is my monthly bill calculated?
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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.
Go to page 5 to learn about programs that can help lower your costs.
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 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.
- 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.
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
Once your health or drug plan reviews your participation request, they’ll send you a letter 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
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Example 1: 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: |
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$2,100 [annual out-of-pocket maximum] -$0 [no out-of-pocket costs before using this payment option] = $2,100 = $175 [your “maximum possible payment” for the first month] |
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Then, we figure out what you’ll pay for January:
For February and the rest of the months left in the year, we calculate your payment differently: |
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$325 [remaining balance] + $500 [new costs] = $825 = $75 [your payment February] 11 [remaining months in the year] |
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We’ll calculate your March payment like we did for February: |
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$750 [remaining balance] + $500 [new costs] = $1,250 = $125 [your payment March] 10 [remaining months in the year] |
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In April, when you refill your prescriptions again, we will calculate like we did for March. |
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$1,125 [remaining balance] + $500 [new costs] = $1,625 = $180.56 [your payment April ] 9 [remaining months in the year] |
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In May, you will have a partial amount remaining and then 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 May you won’t add any new out- of-pocket costs for the rest of the year $1,444.44 [remaining balance] + $100 [new costs] = $1,544.44 = $193.05/$193.06 [your payment for May and all remaining months in the year ] 8 [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. |
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Example 1: Start participating in January with high drug costs early in the year |
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Month |
Your drug costs (without this payment option) |
Your monthly payment (with this payment option) |
Notes |
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January |
$500 |
$175 |
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. |
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February |
$500 |
$75 |
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March |
$500 |
$125 |
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April |
$500 |
$180.56 |
This month you reached the annual out-of-pocket maximum ($2,100 in 2026). You’ll have no new out-of-pocket drug costs for the rest of the year |
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May |
$100 |
$193.05* |
*You’ll still get your $500 drugs each month, but because you’ve reached the annual out-of-pocket maximum in May with a partial payment, 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 |
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June |
$0.00 |
$193.05 * |
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July |
$0.00 |
$193.05 * |
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August |
$0.00 |
$193.05 * |
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September |
$0.00 |
$193.06 * |
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October |
$0.00 |
$193.06 * |
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November |
$0.00 |
$193.06 * |
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December |
$0.00 |
$193.06 * |
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Total |
$2,100.00 |
$2,100.00 |
You’ll pay the same total amount for the year, even if you don’t use this payment option. |
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If you’re concerned about paying $500 each month from January to partially in May, this payment option will help you manage your costs. If you prefer to pay $500 each month for 4 months, $100 for one month 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. |
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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:
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$2,100 [annual out-of-pocket maximum] -$0 [no out-of-pocket costs before using this payment option] = $2,100 = $175 [your “maximum possible payment” for the first month] |
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Then, we figure out what you’ll pay for January:
For February and the rest of the months left in the year, we calculate your payment differently: |
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$0 [remaining balance] + $80 [new costs] = $80 = $7.27 [your payment February] 11 [remaining months in the year] |
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We’ll calculate your March payment like we did for February: |
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$72.73 [remaining balance] + $80 [new costs] = $152.73 = $15.27 [your payment March] 10 [remaining months in the year] |
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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. |
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Example 2: Start participating in January with consistent costs throughout the year |
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Month |
Your drug costs (without this payment option) |
Your monthly payment (with this payment option) |
Notes |
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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. |
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February |
$80.00 |
$7.27 |
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March |
$80.00 |
$15.27 |
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April |
$80.00 |
$24.16 |
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May |
$80.00 |
$34.16 |
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June |
$80.00 |
$45.59 |
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July |
$80.00 |
$58.93 |
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August |
$80.00 |
$74.92 |
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September |
$80.00 |
$94.93 |
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October |
$80.00 |
$121.59 |
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November |
$80.00 |
$161.59 |
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December |
$80.00 |
$241.59 |
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Total |
$960.00 |
$960.00 |
You’ll pay the same total amount for the year, even if you don’t use this payment option. |
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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. |
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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: |
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$2,100 [annual out-of-pocket maximum] -$12 [no out-of-pocket costs before using this payment option] = $2,088 = $232 [your “maximum payment” for the first month] |
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Then, we figure out what you’ll pay for April:
For May and the rest of the months left in the year, we calculate your payment differently: |
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$385 [remaining balance] + $4 [new costs] = $389 = $48.63 [your payment February] 8 [remaining months in the year] |
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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. |
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Example 3: Start participating in April with varying costs throughout the year |
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Month |
Your drug costs (without this payment option) |
Your monthly payment (with this payment option) |
Notes |
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January |
$4.00 |
$4.00* |
*You made these payments directly to the pharmacy before you started participating in the Medicare Prescription Payment Plan. |
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February |
$4.00 |
$4.00* |
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March |
$4.00 |
$4.00* |
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April |
$617.00 |
$232 |
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. |
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May |
$4.00 |
$48.63 |
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June |
$4.00 |
$49.20 |
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July |
$124.00 |
$69.86 |
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. |
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August |
$4.00 |
$70.66 |
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September |
$4.00 |
$71.66 |
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October |
$124.00 |
$112.99 |
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. |
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November |
$4.00 |
$115 |
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December |
$4.00 |
$119 |
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Total |
$889.00 |
$889.00 |
You’ll pay the same total amount for the year, even if you don’t use this payment option. |
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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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