The Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan is a new program that goes into effect on January 1, 2025. It is one of several changes to Medicare Part D benefits that are rolling out between 2023 and 2029, as part of the Inflation Reduction Act passed by Congress in 2022.

All Medicare Part D plans—including Tufts Health Plan—are required to offer the Medicare Prescription Payment Plan.

What is the Medicare Prescription Payment Plan?

The Medicare Prescription Payment Plan provides members with the option to spread out-of-pocket Medicare Part D drug costs across the calendar year (January–December). This means you can pay for your prescriptions in monthly installments, rather than all at once at the pharmacy. Enrollment in the payment plan is optional.

All Medicare-covered Part D prescriptions are eligible to be paid for through the payment plan. For more information, click here to view the Medicare Prescription Payment Plan Facts Sheet.

How does it work?

When you sign up for the Medicare Prescription Payment Plan, your prescription drug costs are split equally across the remaining months of the calendar year. The earlier in the year you join, the more months you have to pay your balance, and the lower each monthly payment may be.

You will not pay the pharmacy at the time of pick up or placement of a home delivery order. Instead, you will receive a bill each month from OptumRx (our pharmacy benefit manager).

If you are unsure of the cost of your drug at the time of pick up or ordering, you can contact Member Services at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711), or ask the pharmacist.

Does the payment plan save me money?

The Medicare Prescription Payment Plan does not save you money or lower your drug costs.

In a calendar year, you pay the same amount you would have paid out-of-pocket at the pharmacy if you weren’t enrolled in the payment plan.

But, the Inflation Reduction Act introduced another change taking effect in 2025 that may help you save: a lower Part D maximum out-of-pocket. For 2025, the maximum is $2,000. This means you can pay up to, but no more than, $2,000 between January and December for your prescription drugs (your plan will pay your Part D expenses after this amount).

Who benefits from using this program?

You’re most likely to benefit from this program if you:

Have high drug costs earlier in the calendar year, or
Are likely to reach the $2,000 maximum out-of-pocket earlier in the calendar year

By enrolling earlier in the year (before September), you have more months to spread out your drug costs. For example, if your out-of-pocket drugs costs are $1,200, you’d pay:

$100 per month if you enrolled in the payment plan in January ($1,200 split across 12 months), but
$400 per month if you enrolled in the payment plan in October ($1,200 split across 3 months)

Who may not benefit from using this program?

The payment option may not be the best choice for you if:

Your yearly drug costs are low – For example, the benefit of splitting a $20 prescription across 12 months (approximately $1.67 per month) may outweigh the worry of having to pay a bill each month.
Your drug costs are typically the same each month – For example, if you fill your prescriptions for $100 every month, the payment plan would not result in a lower monthly bill (it would average out to $100 per month).
You’re considering signing up late in the calendar year (after September) – See above for an example.
You don’t want to change how you pay for your drugs.
You get or are eligible for Extra Help from Medicare – See below for more information.
You get or are eligible for a Medicare Savings Program.
You get help paying for your drugs from other organizations, like Prescription Advantage (the Massachusetts state pharmaceutical assistance program) , a coupon program, or other health coverage.

Do I have to participate in the payment plan?

No. The Medicare Prescription Payment Plan is optional, and members join on an opt-in basis.

Is there a cost to use the payment plan?

There is no cost to you to join or use the Medicare Prescription Payment Plan. There are no fees or interest, even for late payments.

How do I enroll in the Medicare Prescription Payment Plan?

You can enroll at any point during the 2025 calendar year. There are multiple ways to enroll:

Call Member Services at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711)
Mail in or fax the paper enrollment form found here for HMO and here for PPO to:
- Point32Health
  1 Wellness Way
  MS D3
  Canton, MA 02021-9936
Enroll online through your Medicare Prescription Payment Plan Account. This sign up link should only be used by active Tufts Health Plan members.

Alternatively, if you are enrolling in Tufts Health Plan during the Medicare Annual Enrollment Period (Oct. 15, 2024–Dec. 7, 2024), you can sign up for the payment plan between those dates using OptumRx’s online enrollment form.

Your enrollment will be processed within 24 hours.

What happens if I must urgently fill a prescription (and cannot wait 24 hours for my election form to be processed)?

Please call Member Services at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711) to discuss your options.

If the following conditions are met, you can pay for your prescription(s) out-of-pocket, and Tufts Health Plan will retroactively enroll you in the Medicare Prescription Payment Plan and reimburse your out-of-pocket costs:

You believe that any delay in filling your prescription(s) due to the 24-hour processing window may seriously jeopardize your life, health, or ability to regain maximum function, and

How is my bill calculated?

You will be billed for any prescriptions that you have filled. You balance includes any prescriptions filled that month, plus any previous month’s balance, divided by the number of months left in the year.

What if I believe Tufts Health Plan has made a mistake with my bill?

If you believe there is an error on your bill, please contact Member Services at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711) for assistance with resolving the issue.

If you have concerns about Tufts Health Plan and/or the Medicare Prescription Payment Plan, you have the right to follow the grievance process found in your Evidence of Coverage, available at thpmp.org/documents.

What happens if I miss a payment?

If you miss a payment, you’ll receive a reminder from us . There are no fees or interest for a late payment. However, if you do not pay your bill by the date listed in the reminder, you will be removed from the Medicare Prescription Payment Plan.

If you are removed from the Medicare Prescription Payment Plan, you will still be enrolled in your health plan.

What if I have concerns about my ability to pay for my prescriptions?

Always pay your monthly premium first (if you have one), so you do not lose your health and drug coverage.

Assistance, including Extra Help (see below), is available. See 10 Ways to Lower Your Prescription Drug Costs.

Do I qualify for Extra Help to help lower the cost of my prescriptions?

The Low-Income Subsidy (LIS) program, also known as “Extra Help,” is a federal program that helps with the costs of your prescription drugs – including premiums, deductibles, coinsurance, and other costs.

One of the 2024 changes under the Inflation Reduction Act was the expansion of Extra Help to individuals with incomes up to 150% of the federal poverty level and who meet certain resource requirements. Learn more about qualifying for Extra Help.

For those who qualify, enrolling in Extra Help is likely to benefit you more than enrolling in the Medicare Prescription Payment Plan.

You can apply for Extra Help at the Social Security administration.

Can I leave the Medicare Prescription Payment Plan?

Yes. You can leave at any time by calling member services or disenrolling through your Medicare Prescription Payment Plan Account after January 1, 2025. You are responsible for paying any balance you still owe, which you can pay all at once or be billed monthly. After leaving, you’ll pay the pharmacy directly for new out-of-pocket drug costs.

Leaving the payment plan will not affect your enrollment in your health plan or its benefits. This sign up link should only be used by active Tufts Health Plan members.

Where can I find more information?

More information is available on our website, including:

Our Member Services team is here to help answer any questions you have about the Medicare Prescription Payment Plan. Call us at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711).