Welcome

Will this help me?

Depending on your situation. 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. Go to Medicare.gov/prescription-payment-plan/will-this-help-me to answer a few questions and find out if you’re likely to benefit from this payment option.

Please see Low Income Subsidy-Medicare Extra Help tab for more information about the LIS program that can be more advantageous than participation in the Medicare Prescription Payment Plan.

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.
• If you’re in a zero-dollar copayment/coinsurance pharmacy plan.

How does it work?

When you fill a prescription for a drug covered by Part D, you won't pay the pharmacy (including mail order and specialty pharmacies). Instead, you'll get a bill each month from Optum RX on behalf of Ultimate Health Plans.

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 your Pharmacy Benefit Manager, Optum Rx at 800-311-7517 or ask the pharmacist.

This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs

What happens after I sign up?

Once your health or drug plan reviews your participation request, they’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, your plan 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 Optum Rx at 800-311-7517 or ask the pharmacist.

• Each month, your plan will 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. 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.

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 Medicare drug coverage annual out-of-pocket maximum ($2,000 in 2025).

The prescription drug law caps your out-of-pocket drug costs 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.

Please reference FAQ documents below in Where can I get more information tab for more details on how billing statements are calculated.

How do I leave?

You can leave the Medicare Prescription Payment Plan at any time by contacting Optum RX. Members may also opt out of the program via the Optum RX member portal. Leaving won’t affect your Medicare drug coverage and 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 happens if I change my health plans?

If you leave your current plan or change to a new 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.

Urgent Retroactive enrollment:

If you believe you like to register for the program but need to fill a prescription immediately, please call Optum RX at 844-368-8729 to discuss your Options.

Retroactive election guidelines:

• The Part D enrollee believes that any delay in filling the prescription(s) due to the 24 hours timeframe required to process their request to opt in in may seriously jeopardize their life, health, or ability to regain maximum function; and
• The Part D enrollee requests retroactive election within 72 hours of the date and time the urgent claim(s) were adjudicated.

After approval of your participation in the Medicare Prescription Payment Plan, you’ll get a letter with information about how to pay your bill. This will be known as your billing statement.

You can also access your billing statements and make online payments through your pharmacy member portal. Please click on the icon below to access or register for the pharmacy member portal.

What happens if I don't pay my bill?

You’ll get a reminder from your health or drug plan 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 about paying both your monthly plan premium and Medicare Prescription Payment Plan bills, go to What programs can help lower my costs for information about programs that can help lower your costs.

Call Optum RX if you think they made a mistake with your Medicare Prescription Payment Plan bill. If you think they made a mistake, you have the right to follow the grievance process found in your Member Handbook or Evidence of Coverage.

• Optum RX: To get more information. If you need to pick up a prescription urgently, call the dedicated line at 844-368-8729 to discuss your options.
• Medicare: 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.
• FAQ's:

Medicare extra help enrollment, for those who qualify, is likely to be more advantageous than participation in the Medicare Prescription Payment Plan.

Who qualifies for Medicare Extra help?

• Live in the United States
• Be enrolled in or eligible for a Part D prescription drug plan
• Meet income limit
• Meet resource limit

Medicare Extra Help 2025 limits:

Your Situation	Income limit	Resource limit
Single	$23,475.00	$17,600.00
Married couple living together	$31,725.00	$35,130.00

Income refers to how much money you (and your spouse if you’re married) make in a calendar year.

Resources include the value of the things you own. Some examples include:

• Real estate (other than your primary residence)
• Bank accounts (checking, savings and certificates of deposit)
• Stocks
• Bonds (including U.S. Savings Bonds)
• Mutual funds
• Individual Retirement Accounts (IRAs)
• Cash at home or anywhere else

Benefits of Medicare Extra Help Program:

“Extra Help” supports people who are on Medicare and qualify for their state’s Medicaid program. 2025 benefits include.

• No or reduced monthly premium
• No annual dedutible
• Paying no more than $4.90 for each generic/preferred multi-source drug or biosimilar
• Paying no more than $12.15 for all other drugs

Once your total drug costs (including certain payments made on your behalf, like through the Extra Help program) reach $2,000, you’ll pay $0 for each covered drug.

How Do I apply for Extra Help?

• Online - Go to the Social Security Administration’s website
• Phone - Call 800-772-1213 (TTY: 800-325-0778)
• In person - Visit your local Social Security office

Note: If you don’t qualify for “Extra Help” now, you can reapply at any time if your income and resources change.

Sources

Understanding the Extra help With Your Prescription Drug Plan

Help with drug costs

Who can help me decide if I should participate?

• Your Pharmacy Benefit Manager, Optum RX: To get more information call the dedicated line at 844-368-8729 to discuss your options.
• Medicare: Visit Medicare.gov/prescription-payment-plan to learn more about this payment option and if it might be a good fit for you.
• State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get the phone number for your local SHIP and get free, personalized health insurance counseling.

What programs can help lower my 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. Visit ssa.gov/medicare/part-d-extra-help to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov/ExtraHelp to learn more.
• Medicare Savings Programs: State-run programs that might help pay for some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit Medicare.gov/medicare-savings-programs to learn more.
• 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. Visit go.medicare.gov/spap to learn more.
• Manufacturer 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.

Many people qualify for savings and don’t realize it. Visit Medicare.gov/basics/costs/help , or contact your local Social Security office to learn more. Find your local Social Security office at ssa.gov/locator/ .

If you feel like there has been a mistake made with the Medicare Prescription Payment plan, please call 844-368-8729 to file your complaint.

Members can also:

• Fax: 1-800-313-2798
• Write: Ultimate Health Plans, Inc., Appeals & Grievances Department, PO Box 6560, Spring Hill, FL 34611
• Medicare Website: You can also submit a complaint about our plan directly to Medicare. To submit an online complaint to Medicare, click here.