Medicare Prescription Payment Plan
An option for managing your monthly costs
The Medicare Prescription Payment Plan is a new option in the prescription drug law. It is for members who have a Medicare drug plan or Medicare health plan that has drug coverage (like CareAdvantage). It works with members’ drug coverage to spread out-of-pocket drug costs across the calendar year (January–December) with monthly billing.
Starting on January 1, 2025, CareAdvantage members can choose to join the Medicare Prescription Payment Plan any time during the calendar year. Participation is voluntary: members can choose to opt in to this program but do not have to.
As a CareAdvantage member, this payment option likely will not help you because:
- You may already get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP).
- You have low, consistent drug costs. See an example of how this payment option works if you have low, consistent monthly costs.
- This program does not lower your drug costs or save you any money. You would still pay the same amount for your medications as you do now.
Opt in to the Medicare Prescription Payment Plan
Program costs
Joining and participating
There is no cost to join and participate in the Medicare Prescription Payment Plan.
Copays
When members who join the Medicare Prescription Payment Plan fill prescriptions for drugs covered by Medicare Part D, they do not pay copays to the pharmacy (including mail order and specialty pharmacies). Instead, they get a bill each month with all their copays for the month. (Members who have a plan premium also get a separate bill for prescription drugs rather than paying the pharmacy.)
Members who do not pay these monthly bills get reminder letters. There are no fees or interest charged on late payments. Members who do not pay within 60 days are dropped from the Medicare Prescription Payment Plan but remain in CareAdvantage.
Members’ payments might change each month, so they might not know what their exact bill will be ahead of time. Future payments might increase when they fill a new prescription (or refill an existing prescription). That is because, as new out-of-pocket costs get added to their monthly payment, there are fewer months left in the year to spread out their remaining payments.
Urgent election
Members who need a high-cost prescription urgently and want to join the Medicare Prescription Payment Plan can call HPSM's CareAdvantage Unit to learn more. Members who paid for an urgent prescription before joining the Medicare Prescription Payment Plan may be able to get paid back if both of these conditions are met:
- The member believes that waiting 24 hours to join could seriously harm their health.
- The member asked to join within 72 hours of when they paid for their urgent prescription.
If these conditions are met, HPSM will process the request and reimburse the member for the prescription cost within 45 days. If the member asked to join more than 72 hours after paying for the urgent prescription, HPSM will tell them that they can choose to file an appeal.
Opting out of the Medicare Prescription Payment Plan
Members can quit the Medicare Prescription Payment Plan at any time by calling our CareAdvantage Unit at 1-866-880-0606 (TTY: 1-800-735-2929). Phone hours are open Monday - Sunday, 8:00 a.m. to 8:00 p.m. Opting out of the Medicare Prescription Payment Plan does not change members’ Medicare benefits, including drug coverage.
Once members opt out, they are not charged any more out-of-pocket costs. However, they still need to pay any:
- New out-of-pocket costs charged by the pharmacy.
- Outstanding balances (which can either be paid all at once or monthly as bills are received).
- To learn more about the Medicare Prescription Payment Plan, read the fact sheets from the Centers for Medicare & Medicaid Services (parts 1 and 2).
- If you have questions about the Medicare Prescription Payment Plan (such as whether you should apply), contact HPSM's CareAdvantage Unit.
- To file a complaint about the Medicare Prescription Payment Plan, follow these instructions.