Medicare Prescription Payment Plan

Once Medical Mutual reviews your participation request, we’ll send you a letter confirming your participation in the Medicare Prescription Payment Plan. Then, when you get a prescription for a drug covered by Part D (including mail order and specialty pharmacies), we will automatically let the pharmacy know that you’re participating in this payment option.

You won’t pay the pharmacy for the prescription. Instead, Medical Mutual will send you a bill for the amount you owe for your prescriptions, when bill is due, and how to make a payment. You’ll get a separate bill for your monthly plan premium (if you have one).

Your monthly bill is based on what you would have paid for any prescriptions you get, plus your previous month’s balance (if applicable), divided by the number of months left in the year. All plans use the same formula to calculate your monthly payments.

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.

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 toll free at 1-800-982-3117 (TTY: 711) or ask the pharmacist.

In a single calendar year (January – December), you’ll never pay more than the total amount you would have paid out of pocket to the pharmacy if you weren’t participating in this payment option.

The prescription drug law caps your Medicare drug coverage annual out-of-pocket maximum 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. 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 (before September), gives you more months to spread out your drug costs. Answer a few questions here 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.

View sample calculations of how a monthly bill is calculated.

You’ll get a reminder from Medical Mutual if you miss a payment. 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 don’t pay your bill, you’ll be removed from the Medicare Prescription Payment Plan. 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 MedMutual Advantage plan monthly premium first (if you have one), so you don’t lose your drug coverage.

If Medical Mutual receives an unmarked payment from you and we cannot determine whether to credit your premium or Medicare Prescription Payment Plan balance, we will always elect to credit your premium payment account.

Call Medical Mutual Customer Care toll free at 1-800-982-3117 (TTY: 711) if you think we made a mistake about your Medicare Prescription Payment Plan bill. If you think we made a mistake, you have the right to follow the grievance process found in your Member Handbook or Evidence of Coverage.

If you have concerns about your Medicare Prescription Payment Plan, you can file a complaint (also known as a grievance). Filing a complaint ensures that your concerns are heard and addressed, helping to improve the quality of care and services you receive under your Medicare Prescription Payment Plan.

Types of Complaints

You can file a complaint about various issues, including:

• Customer Service: Problems with how you were treated or the service you received.
• Access to Specialists: Difficulty finding specialists within your plan.
• Information from Medical Mutual: Receiving unwanted materials or notices that don’t comply with Medicare rules.
• Drug Errors: Issues like receiving the wrong medication or drugs that interact negatively.

Filing a Complaint

1. Timing: You must file your complaint within 60 days from the date of the event that led to the complaint.
2. Methods:

• Phone: Call Medical Mutual directly at 1-800-982-3117 (TTY: 711)  to file a complaint.
• Writing: Submit your complaint in writing to Medical Mutual.
• Online: Use the Medicare Complaint Form available on the Medicare website.

Response Time

• Medical Mutual must notify you of our decision generally no later than 30 days after receiving your complaint.
• If your complaint is about Medical Mutual’s refusal to make a fast coverage determination or redetermination and you haven’t received the drug, we must respond within 24 hours.

Additional Help

If you need assistance with filing a complaint, you can contact your State Health Insurance Assistance Program (SHIP) for free, personalized help.

Log in to your My Health Plan account or call Medical Mutual Customer Care toll free at 1-800-982-3117 (TTY: 711)  to start participating in this payment option.

• In 2024 for 2025: If you want to participate in the Medicare Prescription Payment Plan for 2025, contact us now. Your participation will start January 1, 2025.
• During 2025: Starting Jan. 1, 2025, you can contact us to start participating in the Medicare Prescription Payment Plan anytime during the calendar year.

Remember, this payment option may not be the best choice for you if you sign up late in the calendar year (after September). This is because as new out-of-pocket drug costs are added to your monthly payment, there are fewer months left in the year to spread out your payments.

If you pay for your medication at the pharmacy because you believe that any delay in filling the prescription(s) due to the 24 hours timeframe required to process your Medicare Prescription Plan Payment request to opt in in may seriously jeopardize your life, health, or ability to regain maximum function, you can contact Medical Mutual Customer Care to request a retroactive enrollment.

You must request retroactive election within 72 hours of the date and time the urgent claim(s) occurred at the pharmacy.

Change In Health Plans

The program also accommodates mid-year plan election changes, allowing you to switch plans if necessary while maintaining your participation in the payment plan.

You can leave the Medicare Prescription Payment Plan at any time by contacting us. Leaving won’t affect your Medicare drug coverage and other Medicare benefits. 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 then pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.

If you leave your current plan, change to a new Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage), your participation in the Medicare Prescription Payment Plan will end. Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.

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. Find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Learn more about getting extra help from Medicare here.

Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit the Medicare website to learn more about savings programs.

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. Learn more about SPAPs.

Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs)): Programs from drug manufacturers to help lower drugs costs for people with Medicare. Learn more about PAPs.

Many people qualify for savings and don’t realize it. Visit the Medicare website or contact your local Social Security office to learn more. Find your local Social Security office.

The Medicare Low-Income Subsidy (LIS) program, also known as “Extra Help,” is a federal initiative designed to assist Medicare beneficiaries with limited income and resources in paying for prescription drugs. This program helps cover costs such as monthly premiums, annual deductibles, and prescription co-payments associated with Medicare Part D.

Starting Jan. 1, 2024, the Inflation Reduction Act has expanded eligibility for the full LIS benefit to individuals with incomes up to 150% of the federal poverty level (FPL), who meet the necessary resource requirements. Previously, full benefits were only available to those with incomes up to 135% of the FPL, with partial subsidies for those up to 150%. This expansion aims to increase access to affordable prescription drugs for more individuals.

How to Apply and Enroll in the LIS Program

To apply for the LIS program, you can:

1. Apply Online: Visit the Social Security Administration (SSA) website and complete the application form.
2. Apply by Phone: Call the SSA at 1-800-772-1213 (TTY 1-800-325-0778) to apply over the phone.
3. Apply in Person: Visit your local Social Security office to request and submit an application.

After submitting your application, the SSA will review your financial situation and notify you of your eligibility. If approved, you will receive assistance with your Medicare Part D costs.

Advantages of LIS Enrollment

For those who qualify, enrolling in the LIS program is often more advantageous than participating in the Medicare Prescription Payment Plan. The LIS program provides more comprehensive financial assistance, reducing out-of-pocket costs for prescription drugs significantly. Additionally, it offers a Special Enrollment Period (SEP) to switch plans if needed, and eliminates any Part D late enrollment penalties

Visit Medicare.gov/prescription-payment-plan, or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.

Medical Mutual Customer Care representatives can assist you with the Medicare Prescription Payment Plan or any questions you have about your Medicare Advantage plan. Representatives are available by calling toll free at 1-800-982-3117 (TTY: 711)

Oct. 1 — March 31: Seven days a week, 8 a.m. to 8 p.m. and April 1 — Sept. 30: Monday to Friday, 8 a.m. to 8 p.m.