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. All Part D plans offer this payment option and your participation is voluntary.
When you join the Medicare Prescription Payment Plan, you no longer pay the pharmacy for your prescription drugs. Instead, Fallon Health works directly with your pharmacy to spread out the costs of all of your prescriptions over the remainder of the calendar year.
Each month, we'll send you a bill showing the amount you owe, when it's due, and how you can make a payment. There's no additional cost and no increase to your prescription copayments. Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs.
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.
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 Medicare.gov/prescription-payment-plan/will-this-help-me (this link takes you away from the Fallon Medicare Plus website) to answer a few questions, and find out if you’re likely to benefit from this payment option.
What happens after I sign up?
- Once we review your participation request, you'll get a letter confirming your participation in the Medicare Prescription Payment Plan. Then:
- When you get a prescription for a drug covered by Part D, Fallon Health 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 us or ask the pharmacist.
- Each month, we'll 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 is my monthly bill calculated?
Your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year. Your payments might change every month, so you might not know what your exact bill will be ahead of time. Future payments might increase when you fill a new prescription (or refill an existing prescription) because as new out-of-pocket costs get added to your monthly payment, there are fewer months left in the year to spread out your remaining payments.
In a single calendar year (January–December), you’ll never pay more than:
- The total amount you would've paid out of pocket to the pharmacy if you weren’t
participating in this payment option.
- The Medicare drug coverage annual out-of-pocket maximum ($2,000 for 2025).
For examples of how a monthly bill is calculated, download the Medicare Prescription Plan Payment Fact Sheet.
What happens if I don’t pay my bill?
You’ll get a reminder 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, you have the right to follow Fallon Health's grievance process.
How do I leave the program?
You can leave the Medicare Prescription Payment Plan at any time by contacting Fallon Health. Leaving won’t affect your Medicare drug coverage or 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 costs?
While the Medicare Prescription Payment Plan helps to manage your costs, it doesn’t lower your 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. You can see if you qualify by calling:
- 1-800-MEDICARE (1-800-633-4227) (24 hours a day, seven days a week).
TTY users call 1-877-486-2048.
- Massachusetts Medicaid office (MassHealth):
1-800-841-2900 (TTY: 1-800-497-4648)
- Social Security Administration: 1-800-772-1213
(TTY: 1-800-325-0778), 8 a.m. to 7 p.m., Monday through Friday.
- 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 (this link takes you away from the Fallon Medicare Plus website) to learn more.
- State Pharmaceutical Assistance Program: Massachusetts has a program called Prescription Advantage. (This link takes you away from the Fallon Medicare Plus website.) This program may also provide assistance in helping you pay for your prescription drug costs. To find out if you qualify for Prescription Advantage, call 1-800-AGE-INFO (1-800-243-4636), TTY: 1-877-610-0241.
- Manufacturer’s 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. (This link takes you away from the Fallon Medicare Plus website.)
Many people qualify for savings and don’t realize it. Visit Medicare.gov/basics/costs/help (this link takes you away from the Fallon Medicare Plus website), or contact your local Social Security office to learn more. Find your local Social Security office at ssa.gov/locator/. (This link takes you away from the Fallon Medicare Plus website.)