Preventing Patient Confusion About the Medicare Prescription Payment Plan: A Guide for the Specialty Pharmacy

The new year will see a major change to OOP drug costs. Technology can help ensure a smooth transition.

By Chris Kepinski

The Medicare Prescription Payment Plan will go into effect on January 1, 2025, transforming the way patient out-of-pocket (OOP) costs are handled. While guidance from the Centers for Medicare & Medicaid Services (CMS) has been somewhat vague, here’s a quick look at what we know about the plan so far, and how specialty pharmacies can leverage technology to navigate both the uncertainty and challenges it might bring.

What is the Medicare Prescription Payment Plan?

The Medicare Prescription Payment Plan was created under the Inflation Reduction Act. According to CMS¹:

“The prescription drug law makes improvements to Medicare by expanding benefits, lowering drug costs, and improving the sustainability of the Medicare program for generations to come. It provides meaningful financial relief for millions of people by improving access to affordable treatments and strengthening Medicare, both now and in the long run.”

Specifically, the plan gives patients with Medicare prescription drug plans (Medicare Part D plans) the option of paying their out-of-pocket prescription costs in monthly installments rather than paying in full up front. Patients who opt in to the program will pay $0 to the pharmacy for covered Part D drugs; the pharmacy will be paid in full by the patient’s Part D plan sponsor, and the sponsor will send the patient a monthly bill for their portion of the medication cost.

Patients will not have to pay any interest or fees for opting into this monthly installment program, nor does this program provide them with a discount.² They will be paying the same amount for their medication that they would be paying otherwise; the only difference is when they pay.

Patient benefits and potential challenges

By offering patients more flexibility in when they pay for their prescriptions, the Medicare Prescription Payment Plan is intended to make medications more affordable and accessible. It lets patients spread out the expense of treatment throughout the year so that they don’t have to struggle to come up with the money to pay a large bill all at once. This will be especially beneficial to patients who have high-cost sharing earlier in the plan year. Patients and their families can decide whether it is in their best financial interest to opt into the program using this tool developed by CMS.

But while many patients stand to benefit from this new payment flexibility, the Medicare Prescription Payment Plan may create some unintended hurdles by adding to patient confusion about OOP costs. For instance, a patient may be told they have no copay when picking up their prescription at the pharmacy, only to later receive a bill in the mail–followed by another bill each month throughout the year.

Unless the payment installment schedule is clearly communicated to the patient when their prescription is filled, they may experience delayed financial stress when the unanticipated bills start arriving. This can lead to feelings of shame and isolation in that the patient may have assumed the medication was free after they were not initially asked for payment, and may therefore be unprepared to pay upon receiving a surprise bill. Moreover, they will not be face to face with a pharmacy technician who can answer their questions when they receive the bills.

In addition to financial stress, confusion about the Medicare Prescription Payment Plan may inadvertently cloud financial transparency, causing patients to lose trust in their pharmacy, as well as in their healthcare provider, Medicare, their Part D sponsor, and the drug manufacturer. It may even discourage or delay patients from seeking medical care in the future because they fear incurring unexplained medical bills that seem to just keep coming.

As the new program goes into effect, the specialty pharmacy will play a key role in preventing this confusion and breakdown of trust by reminding patients of their participation in the program and ensuring they understand when, why, and how they will be billed.

Communication is key, and the specialty pharmacy is the perfect messenger

Although patients will choose whether or not to participate in the Medicare Prescription Payment Plan, that doesn’t mean they will fully understand what they’ve opted into… or even remember that they did so. Changing policies, medical and financial jargon, and the sheer volume of paperwork patients receive from various parties and through various channels regarding their health care and related financial obligations can cause confusion and frustration for even the savviest patients.³

It’s critical that pharmacy staff recognize that patients will need education and reminders around this new program, particularly in its first years.

As likely the final in-person touch point before a patient starts receiving bills for their medication, the specialty pharmacy is uniquely positioned to promote patient understanding of the Medicare Prescription Payment Plan. A $0 copay should serve as an alarm for pharmacy staff to check into whether the patient has opted into the Medicare Prescription Payment Plan, and to remind the patient of what that means. Pharmacies can take advantage of digital tools to make this a simple, routine step rather than a time-consuming, research-heavy process.

How technology can promote financial transparency and patient understanding

In order to keep patients well-informed about their participation in this new program and what bills they can expect, pharmacy staff should have that information at their fingertips. Traditional manual processes and disparate systems can make it difficult to quickly access all relevant patient details such as diagnosis, prescription, history, insurance information (including Medicare Prescription Payment Plan election), and any financial assistance the patient qualifies for. This is especially true for pharmacies that serve a large population and have limited time to spend on each patient interaction.

Fortunately, there are digital solutions that can make it possible to house all of a patient’s information in an integrated environment for quick and easy reference at the time the prescription is filled.

If your specialty pharmacy is using the AssistPoint^Ⓡ platform to manage patient financial assistance and access services, you already know how it enhances efficiency and accuracy by creating a secure, connected, multi-system pharmacy workflow. AssistPoint seamlessly integrates with your pharmacy dispensing system and is integrated with patient support programs offered by manufacturers and charitable foundations, minimizing manual processes and allowing pharmacy staff to rapidly search for patient assistance opportunities, enroll eligible patients, and manage award fulfillment.

Here’s how you can utilize AssistPoint to keep track of a patient’s opt in status to the Medicare Prescription Payment Plan:

The Patient Journey Tab within AssistPoint allows pharmacy staff—from any location, under a single sign on—to quickly access all financial assistance activity for that individual patient in one place. When a patient’s Part D sponsor notifies your pharmacy that a patient has opted in to the Medicare Prescription Payment Plan (which should happen automatically when the script comes in²), you can make note of this directly within their Patient Journey Tab.

With the patient’s Medicare Prescription Payment Plan opt in status captured alongside their other financial assistance information, pharmacy staff can readily access this critical detail and let the patient know that, although they have a $0 copay at the pharmacy when getting the prescription filled, they will be receiving bills from their Part D sponsor to pay the copay in monthly installments. Whether the pharmacy will be able to see exactly how much the patient’s payments will be is not yet known.

By making sure your patients understand their OOP expenses, you can strengthen their trust in the healthcare system and help improve their health and financial outcomes.

If you’re not yet using AssistPoint, now is a great time to start! To learn more about what the platform can do for your specialty pharmacy and your patients, submit a contact form at annexushealth.com/contact and a member of the Annexus Health team will be in touch.

Additional resources

Patients and healthcare providers can find more, helpful information about the Medicare Prescription Payment Plan at the following links:

• Medicare.gov: What’s the Medicare Prescription Payment Plan?
• CMS.gov: Medicare Prescription Payment Plan Guidance
• The National Association of Medication Access & Patient Advocacy (NAMAPA): Stay Up to Date With Changes in Medicare Part D for 2025