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Medicare Prescription Payment Plan

Effective January 1, 2025, 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). This new payment option is free to those who opt in. All plans offer this payment option and participation is voluntary

For example, if you need a specialty drug at the beginning of the year and your cost share is more than $2,000, this program will spread payments out at $166.76 per month, rather than you paying the total $2,000 expense all at once. 

Here are examples and explanations of how the Medicare Medications Prescription Payment Plan monthly payments are calculated.

It is important to note, each member who opts into this program may have different payments. How is that possible? Each prescription and its associated costs can alter a member's monthly Medicare Prescription Payment Plan payment. Since each member may need different medications - it is possible that no two member's monthly payments will be identical.

Here is an example of how the monthly payment is calculated:

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:

 
 
 
 
 
 
 
 
M3P Maximum Possible Payment

Example 1: Start participating in January with high drug costs early in the year

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. 

Example 2: Start participating in January with consistent costs throughout 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 with drug coverage.

Example 3: Start participating in April with varying costs throughout the year

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. 

Even though your payment may vary each month, by the end of the year, you’ll never pay more than:

  • The total amount you would have paid out-of-pocket if you did not participate in the Medicare Prescription Payment Plan.
  • 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.

FAQs

Am I likely to benefit from this program?

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

Financial Implications of Participation in the Medicare Prescription Payment Plan

  • This payment option might help you manage your monthly expenses, but it does not save you money or lower your drug costs.
  • Each month you’ll continue to pay your health or drug plan premium (if you have one), and you’ll get a bill from your plan to pay for your prescription drugs (instead of paying the pharmacy).
  • The program is free to join 
  • There are no fees or interest charged under this program

    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.

How do I pay my bill?

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

What happens if I don’t pay my bill?

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 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 SummaCare Medicare plan.

Always pay your health or drug plan monthly premium first (if you have one), so you don’t lose your drug coverage. 

How do I opt into the Program?

You have several ways to opt into the Medicare Prescription Payment Plan Program:

You can print and fill out the Medicare Prescription Payment Plan Participation Request Form found here
Submit your completed form to:
SUMMACARE INC
PO BOX 3620
AKRON OH 44398-0998

You can complete the participation request form online at summacare.com/plancentral

You can call us at 330.996.8885 or toll free at 800.996.6250 (TTY 800.750.0750) to submit your request via telephone. 

How quickly will my election request be processed?

The timing of processing your request depends on when your request is received. 

If you elect into the Program prior to the plan year, we will process your election request within 10 calendar days of receipt or within the calendar days before your plan enrollment starts, whichever is shorter. We will confirm enrollment into your SummaCare Medicare Plan with CMS, before processing your request into the Medicare Prescription Payment Plan. 

If you elect into the Program during the plan year, we will process your election request within 24 hours.

If you meet certain conditions, we may process an Urgent Medicare Prescription Payment Plan Election

An urgent retroactive election may be necessary if you have certain urgent prescription fill(s) for which you may pay the associated cost sharing before your program election request was received and processed. An urgent retroactive request will be processed if both the following conditions are met:

  • You believe that a delay in filling the prescriptions due to the 24 hours timeframe required to process the request to opt in may seriously jeopardize your life, health or ability to regain maximum function; and
  • You request retroactive election within 72 hours of the date and time the urgent prescriptions were processed at the pharmacy.

How do I leave the Program?

You can leave the Medicare Prescription Payment Plan at any time by calling us at 330.996.8885 or toll free at 800.996.6250 (TTY 800.750.0750). 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 programs can help lower my drug costs?

If you have limited income and resources, find out if you are eligible for one of these programs:

Low-Income Subsidy Program (LIS) or "Extra Help"

LIS is a Medicare program to help people with limited income and resources pay for Medicare drug coverage (Part D) premiums, deductibles, coinsurance and other costs. 

Effective January 1, 2024, the Inflation Reduction Act expanded the LIS program to be fully available to those with limited resources and earn less than 150% of the federal poverty level. 

If you qualify for the LIS program, this program is likely to be more advantageous to you than participating in the Medicare Prescription Payment Plan, as it may lower your drug costs. To find out more and see if you qualify please click here 

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.


Information about how to file a complaint, grievance or appeal regarding the Medication Prescription Payment Plan can be found here
 

For More information regarding the Medicare Prescription Payment Plan you can:

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