Medicare Prescription Payment Plan

1. Overview of the program 
   
   The Medicare Prescription Payment Plan, established by the Inflation Reduction Act of 2022 and set to commence on January 1, 2025, is intended to assist Medicare Part D members in managing the financial responsibility associated with out-of-pocket (OOP) costs for their prescription drugs. This program gives Medicare Part D members the option to pay their out-of-pocket prescription drug expenses in monthly amounts, rather than in one sum at the pharmacy. One of the key benefits of this program is its potential to support medication adherence among members, ensuring they maintain prescribed treatment regimens for improved health outcomes.

   The program aims to enhance the overall quality of life for Medicare Part D enrollees, alleviating financial stress and empowering individuals to prioritize their health and well-being.
   
   This program can be helpful for members who incur high out-of-pocket costs for Part D drugs $600 or more at the beginning of the year. The member that selects this payment option will continue to pay their plan premium each month (if they have one) and will receive a bill from GlobalHealth to pay for their prescriptions (instead of paying the pharmacy). All Medicare Advantage plans will offer this payment option, and participation is voluntary. This payment option might help you manage your expenses, but it doesn’t save you money or lower your medication costs.  

2. How will my costs work with this payment option? 
   

   The new Part D drug coverage model caps a member’s out of pocket costs at $2,000 in 2025 and eliminates the coverage gap phase (known as the “coverage gap” or “donut hole”). This means you’ll never pay more than $2,000 in out-of-pocket costs for medications in 2025. This is true for everyone with Medicare Part D drug coverage, even if you don’t enroll in the Medicare Prescription Payment Plan. If you enroll in the program, when you get a prescription for a Part D covered drug, you won’t pay the pharmacy (including mail-order and specialty pharmacies). Instead, your health plan will pay the pharmacy the full cost of the prescription, including the participant’s copay or coinsurance, and then you will receive a bill each month from GlobalHealth. Your monthly bill is based on what you would have paid for any prescriptions you get, plus the previous month’s balance, divided by the number of months left in the year.  

   Note: Your payments may change each month, so you may not know your exact bill in advance. Future payments may increase when you fill a new prescription or refill an existing prescription because as new costs are added to your monthly payment, there are fewer months left in the year to spread out your remaining payments. 

3. How do I know if this payment option might not be right for me?  
   

   This payment option may not be the best option for you if:  

   • You have a Low-Income Subsidy (LIS) Coverage. 
   • Your annual drug costs are low.  
   • Your drug costs are the same every month.  
   • You’re considering signing up for the payment option at the end of the year (after September).  
   • You don’t want to change the way you pay for your medications.  
   • You get help paying for your medications from other organizations, such as a State Pharmaceutical Assistance Program (SPAP) or a charity.

4. Examples of how a monthly bill is calculated

   The Medicare Prescription Payment Plan allows participants to manage their out-of-pocket costs for covered Part D drugs throughout the year (January – December) through monthly billing. Until the participant opts into the program and incurs OOP costs for covered drugs, they will not receive any monthly bills under this program.

   Once out-of-pocket costs are incurred, in either the deductible phase or the initial coverage phase, subsequent OOP costs for covered Part D drugs will be billed monthly while the participant remains in the program. The calculations do not reduce the total costs that a participant will pay over the year; instead, participants in the Medicare Prescription Payment Plan can spread their OOP costs for throughout the year (January – December) calculated according to the formula established in the Inflation Reduction Act of 2022.

   It's important to note that opting into the program facilitates the spreading of OOP costs over the year; however, the total incurred costs and the timing of True Out-of-Pocket (TrOOP) Expenditure accrual do not change.

   For participants obtaining prescriptions for extended periods (e.g., 90-day supplies), the entire OOP cost of such prescriptions is attributed to the month the prescription was filled, not distributed over the duration covered by the prescription. For example, if a participant incurs $300 in OOP costs for a 90-day supply dispensed in January, the full $300 is considered incurred in January

   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 GlobalHealth 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]

   = $166.67 [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 ($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]

   =$75.76 [your payment for February]

    

   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]

   =$125.76 [your payment for March]

   In April, when you refill your prescriptions again, you’ll reach the annual out-of-pocket maximum for the year ($2,000 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 out-of-pocket costs for the rest of the year.

    

   $1,131.81 [remaining balance] + $500 [new costs] = $1,631.81 9 [remaining months in the year]

   = $181.31 [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 ($2,000 in 2025).

   However, if you are not able to make the payments each month your monthly payments can increase due to accrued OOP costs not paid. You won’t pay any interest or fees, even if your payment is late

   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. And if applicable, your Part D late enrollment penalty (LEP) each month. 

    

    

    

    

   Example 1: Start participating in January with high drug costs early in the year
   Month	Your drug OOP costs incurred	Your remaining balance in this payment option	Remaining months in the year	Your monthly payment (with this payment option)	Notes
   January	$500.00	$500.00	12	$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	$500.00	$833.33	11	$75.76	This is considering the remaining balance to pay plus the new OOP costs for this month divided between the remaining months in the year.
   March	$500.00	$1,257.58	10	$125.76
   April	$500.00	$1,631.82	9	$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	$1,450.51	8	$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	$1,269.19	7	$181.31*
   July	$0.00	$1,087.88	6	$181.31*
   August	$0.00	$906.57	5	$181.31*
   September	$0.00	$725.25	4	$181.31*
   October	$0.00	$543.94	3	$181.31*
   November	$0.00	$362.63	2	$181.31*
   December	$0.00	$181.31	1	$181.31*
   Total	$2,000.00	$0.00		$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 GlobalHealth for personalized help.

    

   Example 2:

   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 (April), before you fill your prescriptions, you decide to participate in the Medicare Prescription Payment Plan through your GlobalHealth 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]

   = $220.89 [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: $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]

   =$50.01 [your payment for May]

    

   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. However, if you are not able to make the payments each month your monthly payments can increase due to accrued OOP costs not paid. You won’t pay any interest or fees, even if your payment is late.

   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. And if applicable, your Part D late enrollment penalty (LEP) each month.

    

   Example 2: Start participating in April with varying costs throughout the year
   Month	Your drug OOP costs incurred	Your remaining balance in this payment option	Remaining months in the year	Your monthly payment (with this payment option)	Notes
   January	$4.00	N/A	12	$4.00*	*You made these payments directly to the pharmacy before you started participating in the Medicare Prescription Payment Plan.
   February	$4.00	N/A	11	$4.00*
   March	$4.00	N/A	10	$4.00*
   April	$617.00	$617.00	9	$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	$400.11	8	$50.01	This is considering the remaining balance to pay plus the new OOP costs for this month divided between the remaining months in the year.
   June	$4.00	$354.10	7	$50.59
   July	$124.00	$427.51	6	$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	$360.26	5	$72.05	This is considering the remaining balance to pay plus the new OOP costs for this month divided between the remaining months in the year.
   September	$4.00	$292.21	4	$73.05
   October	$124.00	$343.16	3	$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 adding drug costs during the year, but you have fewer months left in the year to spread your payments across.
   November	$4.00	$232.77	2	$116.39	This is considering the remaining balance to pay plus the new OOP costs for this month divided between the remaining months in the year.
   December	$4.00	$120.39	1	$120.39
   Total	$901.00	$0.00		$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 GlobalHealth for personalized help.

    

5. Who can benefit?  
   

   Part D members with high OOP costs earlier in the plan year are more likely to benefit from the Medicare Prescription Payment Plan. Since this program permits members to pay for their Part D medications during the calendar year (January to December), enrollees with high prescription drug cost-sharing will likely benefit most. The two groups that will most likely benefit from the Medicare Prescription Payment Plan will be:  

   • Part D members who incurred out-of-pocket expenses of $2,000 or more between the months of January and September of 2024. Approximately 2% of members will benefit from the Medicare Prescription Payment Plan. (This information is based on the percentage of GlobalHealth members who use specialty medications.) 
   • Part D enrollees with out-of-pocket costs of $600 or more per prescription.  

   This program is not for everyone, as it does not save the enrollee money or reduce the cost of their medications. The member should consider other alternate programs that could lower their drug costs.  

6. Is the Medicare Prescription Payment Plan available for prescription drugs covered by medical coverage (Part B)? 
   

   The Medicare Prescription Payment Plan is NOT available for drugs covered by Medicare Part B.  

   Usually, the drugs covered under Part B are drugs that you would not give yourself, such as drugs you get by injection, by infusion (serum) in the doctor’s office or an outpatient setting, or for insulins given through an infusion pump.

7. The financial implications for the enrollee of participating in the program
   In 2025, the Medicare Prescription Payment Plan will be implemented by the Centers for Medicare & Medicaid Services (CMS) to support members who participate in Medicare Part D Prescription drug plans. As members, it is crucial to understand the financial implications for enrollees under this new program:  
   
   a) No Reduction in Cost-Sharing: it’s important to note that while participating in the Medicare Prescription Payment Plan program helps manage monthly prescription costs, it does not reduce the amount of cost-sharing an enrollee owes for their Medicare Part D prescriptions. Enrollees will still be responsible for their deductible, copayments, and coinsurance as per their specific Part D plan.  
   
   b)Annual Out-of-Pocket Limit: beginning in January 2025, the annual out-of-pocket cost for the Part D benefit will cap at $2,000. This limit restricts the amount enrollees pay for out-of-pocket prescription drugs each year. This means that the members will have up to $2,000 in out-of-pocket costs, and any additional expenses during that plan year will be covered by the Medicare Advantage Part D plan. This applies to everyone with Medicare drug coverage, even if the enrollee doesn’t join the Medicare Prescription Payment Plan. 
   
   c) Free to join: the Medicare Prescription Payment Plan is free and voluntary to join. Enrollees can participate without any registration fees.  
   
   d) There are no additional costs or interest: there will be no additional fees or interest charged under the Medicare Prescription Payment Plan program. Enrollees can manage their prescription drug costs without worrying about additional costs.  
   
   e) Billing and payment: when an enrollee who is already part of the Medicare Prescription Payment Plan fills a prescription for a drug covered by Part D, they won’t pay the pharmacy (including mail-order and specialty pharmacies). Instead, the member will get a monthly bill from the health plan. The monthly bill is based on what the enrollee would have paid for any prescriptions they get, plus the previous month’s balance, divided by the number of months left in the year. 
   
   f) Monthly Payments may vary: the payments for a member that’s already part of the Medicare Prescription Payment Plan might change every month, so the member might not know what their exact bill will be ahead of time. Future payments may increase when filling a new prescription or refill an existing prescription, because new out-of-pocket drug costs get added into the monthly payment.
   
8. Importance of paying monthly bills and implications of not paying monthly bills
   

   It is crucial for members of the Medicare Prescription Payment Plan to comply with paying their monthly bills promptly. GlobalHealth has established processes to ensure compliance with payment deadlines and to address situations where payments are not received on time. Not paying monthly bills may lead to the involuntary termination of the member from the Medicare Prescription Payment Plan. It is important to note that involuntary termination doesn’t compromise being a member of GlobalHealth or a specific drug coverage plan.  

   Grace period for payment 

   GlobalHealth will provide its members with a grace period of two (2) months if they fail to pay the billed amount by the payment due date. This grace period begins on the first day of the month for which the balance is unpaid or the first day of the month following the date the payment is requested, whichever is the latest. During this grace period: 

   • Members can pay the overdue balance to remain in the program. 
   • The participant can be terminated from the program involuntarily once the grace period has concluded. 
   • If a member fails to pay the amount due from the prior year during the required grace period, GlobalHealth may terminate their participation in the program for the new plan year, following the involuntary termination procedures.  
     • If a participant is involuntarily terminated from the Medicare Prescription Payment Plan program by the Part D sponsor (GlobalHealth), a termination notice will be sent within three (3) calendar days after the end of the grace period. 

   Notification requirements 

   If a Medicare Prescription Payment Plan participant fails to pay their monthly billed amount,  they will receive the following notices: 

   1. Initial notice: within 15 calendar days of the payment due date, an initial notice will be sent to the participant explaining that the billed amount has not been paid. (e.g. If your payment is due on January 30th and you didn’t pay it by February 14th you will receive this initial notice). 
   2. Termination notice: if the participant fails to pay the amount due by the end of the grace period, a termination notice will be sent within three (3) business days following the last day of the grace period. This notice informs the participant of their termination from the Medicare Prescription Payment Plan. (e.g. If the grace period starts on February 14th the end date would be on April 15th) 

   These processes and notices ensure transparency and provide members with opportunities to address outstanding balances while maintaining program compliance and continuity of coverage.  

9. Opting In / Out of the Program and Timing Requirements Around Election Effectuation.
   
   1. Process of applying for participation in the program:  

      Members who wish to participate in the Medicare Prescription Payment Plan may apply to enroll in the program beginning October 15, 2024, or during any month of the 2025 calendar year. However, even if you enroll in 2024, the payment plan is effective January 1, 2025. 

      When enrolling in the program throughout the 2025 calendar year, the Medicare Prescription Payment Plan would become effective within 24 hours of the application. The first bill expires the next month after the first Part D prescription drug is dispensed. 

      CMS developed the Medicare Prescription Payment Plan Participation Request Form. This form must be filled for GlobalHealth to know that you would like to participate in the payment option. The form indicates that this is a voluntary payment option that works with the current drug coverage to help the member manage their expenses, but it won’t save them money or lower the drug cost. 

   2. Process for voluntary terminating your participation in the Medicare Prescription Payment Plan:  
      If an enrolled person wishes to withdraw from the Medicare Prescription Payment Plan, they can do so at any time during the plan year (January – December). The member that opts out from the Medicare Prescription Payment Plan program will be responsible to pay any new out-of-pocket costs directly to the pharmacy. The Participant will also be responsible for paying any remaining balance either by one lump sum or finishing its monthly payments.

      The member who wishes to voluntarily terminate must notify GlobalHealth that they do not wish to continue participating in the payment plan by means of a termination request form. If the participant disenrolls from GlobalHealth their participation in the payment plan will be terminated voluntarily. As a result, the member will receive a confirmation of program termination within 10 calendar days of receipt of the application form.  

      Notice of voluntary termination

      GlobalHealth has procedures that allow Part D members participating in the Medicare Prescription Payment Plan to terminate their participation voluntarily. Upon a voluntary termination: 

      • Outstanding balance: GlobalHealth will work with the enrollee to determine how to manage any outstanding balance. This may include options to pay in full or if the enrollee opts to continue paying in monthly amounts, the amounts owed will be billed under the program in monthly installments for the remainder of the plan year. 
      • New out-of-pocket (OOP) costs: after opting out of the payment plan, any new out-of-pocket costs incurred by the individual for covered Part D drugs will need to be paid directly to the pharmacy as part of the copayments or coinsurance.  
      • Notification process: GlobalHealth will process the participant’s voluntary termination request promptly, within 10 calendar days of receiving the request. GlobalHealth will send the individual a notification confirming the termination. Additionally, accurate records of individuals who have voluntarily terminated from the program will be recorded and tracked by GlobalHealth directly.  
10. How can Part D Enrollees File complaints and grievances related to the program?
    

    Ensuring the satisfaction and concerns of our Part D enrollees is a priority for us. We have a comprehensive process for filing complaints and grievances regarding the Medicare Prescription Payment Plan. The process allows enrollees to communicate their concerns and seek resolution promptly. 

    Filing a complaint or grievance 

    Part D members who wish to file a complaint or grievance related to the Medicare Prescription Payment Plan can do so through the following channels:  

    1. You may submit your complaint to the plan.  

    Write: 
    GlobalHealth 
    C/O: Appeals and Grievances  
    P.O. Box 2658 
    Oklahoma City, OK 73101-2658 

    Call:  
    1-866-494-3927 (TTY users call 711). 24 hours a day, seven days a week. 

    Fax: 
    1-405-280-5294  

    You can find more information about what your plan covers in your Evidence of Coverage.  

    You may also call and file a complaint with Medicare at (1-800-633-4227), TTY users should call (877) 486-2048, 24 hours a day/ 7 days a week or visit https://www.medicare.gov/my/medicare-complaint/step1 (by clicking on this link you will be leaving our website). 

11. Retroactive election in the event the Part D sponsor fails to process an election within 24 hours
    

    In the event a Part D member satisfies all program election requirements and, for reasons beyond the individual's control. GlobalHealth is unable to process the election into the program within the required timeframe, the Part D plan must process a retroactive election back to the initial date when the individual should have been admitted into the Medicare Prescription Payment Plan. This should occur no later than 24 hours after the individual provides the necessary information for election into the program.  

    Furthermore, within 45 calendar days GlobalHealth will reimburse the participant back for any out-of-pocket cost-sharing that was paid on or after that date. Afterward, these summed amounts will be included in the monthly bills and must be paid back by the Medicare Prescription Payment Plan participant. 

12. Standards for urgent Medicare Prescription Payment Plan election 
    

    In situations where the Part D enrollee believes that any delay in filling the prescription(s) may seriously jeopardize their life or health, GlobalHealth will process an urgent retroactive election request when made by the Part D enrollee within 72 hours of the date and time the urgent claim(s) were adjudicated. 

    Under this policy, a retroactive election will be processed if all the following conditions are met: 

    • The Part D member believes that any delay in filling the prescription(s) due to the 24 hours timeframe required to process their request to opt in may seriously jeopardize their life, health, or ability to regain maximum function; and  
    • The Part D member requests retroactive election within 72 hours of the date and time the urgent claim(s) were adjudicated. 

    GlobalHealth will handle the reimbursement for all cost sharing paid by the member for the urgent prescription and any covered Part D prescription filled between the date of adjudication of the urgent claim and the date that the enrollee's election is effectuated within 45 calendar days of the election date, following the effectuation of the member’s Medicare Prescription Payment Plan election. GlobalHealth will promptly notify the member of its selection. Afterwards, these amounts will be included in the monthly bills and must be paid back by the Medicare Prescription Payment Plan participant.
    

    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 https://www.ssa.gov/medicare/part-d-extra-help to find out if you qualify and apply. You can also find out more about the Low-Income Subsidy (LIS) program by visiting https://www.cms.gov/training-education/partner-outreach-resources/low-income-subsidy-lis. LIS enrollment, for those who qualify, is likely to be more advantageous than participation in the Medicare Prescription Payment Plan. 

    You can also apply with your State Medical Assistance (Medicaid) office. 

    Visit https://www.medicare.gov/basics/costs/help/drug-costs 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 https://www.medicare.gov/basics/costs/help/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 https://www.medicare.gov/plan-compare/#/pharmaceutical-assistance-program?year=2024&lang=en to learn more. 

      Many people qualify for savings and don’t realize it. Visit https://www.medicare.gov/basics/costs/help, or contact your local Social Security office to learn more. Find your local Social Security office at https://www.ssa.gov/locator/. 

13. Contact information Medicare Prescription Payment Plan 
    

    For personalized assistance and to determine if Medicare Prescription Payment Plan is right for you, please contact our customer service team at 866-494-3927 (TTY users call 711). 24 hours a day, seven days a week.  

    Additional resources regarding the Medicare Prescription Payment Plan: 

    • www.medicare.gov/prescription-payment-plan 
    • CMS Medicare Prescription Payment Plan Fact Sheet (English) 
    • CMS Medicare Prescription Payment Plan Fact Sheet (Espanol) 

To sign up for the Medicare Prescription Payment Plan program, please call us at (866) 494-3927 (TTY users call 711) 24 hours a day, seven days a week or Click Here.