Medicare Prescription Payment Plan

Medicare Prescription Payment Plan

For the first time, beginning in 2025, the prescription drug law, known as the Inflation Reduction Act, requires all Medicare prescription drug plans (Medicare Part D plans) — including both standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage — to offer enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy.

Timeline: Medicare Prescription Payment Plan Implementation (PDF) (July 16, 2024)

Medicare Prescription Payment Plan Part One Guidance

Part one guidance on the Medicare Prescription Payment Plan outlines requirements for Medicare Part D plan sponsors on operational topics such as identifying Medicare Part D enrollees likely to benefit from the program, the opt-in process for Part D enrollees, program participant protections, and the data collection needed to evaluate the program. These requirements apply to the first year of the program, 2025. 

CMS released draft guidance on August 21, 2023, for public comment and published the final guidance on February 29, 2024. 

Fact Sheet: Medicare Prescription Payment Plan Final Part One Guidance (PDF) (February 29, 2024)

Medicare Prescription Payment Plan Final Part One Guidance (PDF) (February 29, 2024)

Medicare Prescription Payment Plan Draft Part One Guidance (PDF) (August 21, 2023)

Summary and Sample Calculations technical memo (PDF) (July 17, 2023)

Medicare Prescription Payment Plan Part Two Guidance

Part two guidance on the Medicare Prescription Payment Plan outlines requirements for Medicare Part D plan sponsors on topics related to outreach and education, pharmacy processes, and operational considerations. These requirements apply to the first year of the program, 2025.

CMS released draft guidance on February 15, 2024, for public comment and published the final guidance on July 16, 2024.

Fact Sheet: Medicare Prescription Payment Plan Final Part Two Guidance (PDF) (July 16, 2024)

Medicare Prescription Payment Plan Final Part Two Guidance (PDF) (July 16, 2024)

Medicare Prescription Payment Plan Draft Part Two Guidance (PDF) (February 15, 2024)

Changes to TrOOP Cost and Calculation of Maximum Monthly Cap Technical Memo (April 25, 2024)

Information Collection Requests (ICRs) for the Medicare Prescription Payment Plan

  • The Medicare Advantage and Prescription Drug Programs: Part C and Part D Explanation of Benefits is approved through March 31, 2027, and is available for viewing at OMB's website. Click "all" to see the full details. 

  • The Collection of Prescription Drug Data from MA-PD, PDP and Fallout Plans/Sponsors for Medicare Part D Payments is approved through April 30, 2027, and is available for viewing at OMB's website. Click "all" to see the full details. 

  • The Medicare Advantage and Prescription Drug Programs: Part C and Part D Medicare Advantage Prescription Drug (MARx) System Updates for the Medicare Prescription Payment Plan Program is approved through May 31, 2027, and is available for viewing at OMB's website. Click "all" to see the full details.  

  • The Medicare Part D Reporting Requirements can be found in the Federal Register. The full text of the ICR can also be found on CMS's PRA Listing website. The 60-day comment period closed on April 2, 2024, and the 30 day comment period closed on June 24, 2024. CMS expects to issue the final package in Summer 2024.

  • The Medicare Advantage and Prescription Drug Programs: Part C and Part D Medicare Prescription Payment Plan Model Documents is approved through July 31, 2025, and is available for viewing at OMB's website. Click "all" to see the full details. 

    • The model materials are available for download here (ZIP). Part D sponsors can use these materials to meet communications and outreach requirements included in the final part two guidance.


Page Last Modified:
07/16/2024 04:15 PM