PHARMACY PLAN COVERAGE

Medicare Prescription Payment Plan

Prescriptions / 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 by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary. If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). Joining the Medicare Prescription Payment Plan does not reduce the amount of your cost-sharing owed for covered Part D prescriptions. This program does not benefit everyone, and you should review the examples, use the payment calculator, or call our plan to understand if you are likely to benefit. There’s no cost to participate in the Medicare Prescription Payment Plan.

What to know before participating

How does it work

When you fill a prescription for a drug covered by Part D, you won’t pay your pharmacy (including mail order and specialty pharmacies). Instead, you’ll get a bill each month from your health or drug plan.

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 plan or ask the pharmacist.

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. If you would like to sign up, you may contact us, and we will process your election enrollment within 24 hours of receipt.

How to sign up

Enroll online at Capital Rx member portal and calculator
Download and complete an election form
Or call 1-877-812-2779 TTY Users Dial 711

If you are already a member click here to manage your payments:
Capital Rx portal

How do you leave the Medicare Prescription Payment Plan?

You can leave the Medicare Prescription Payment Plan at any time and leaving does not affect your Medicare drug coverage or other Medicare benefits. If you still owe a balance, you are required to pay the amount you owe, even though you are no longer participating in the payment plan. You can pay this balance all at once or be billed monthly. You’ll pay the pharmacy directly for any new out-of-pocket prescription costs after you leave the Medicare Prescription Payment Program.

What happens if you don’t pay your bill?

We will send you a reminder if you miss a payment. If you don’t pay your bill by the date listed on the reminder, we can remove you from the Medicare Prescription Payment Program. You are required to pay the amount you owe, but even if your payment is late, you do not pay interest or fees. You will still be enrolled in your HealthTeam Advantage Plan, even if you are removed from the Medicare Prescription Payment Plan.

Medicare Prescription Payment Plan Grievances

How to file a grievance about the Medicare Prescription Payment Program

PHONE/VERBAL

If you’d like to file a verbal grievance by phone, you can call your HealthTeam Advantage HealthCare Concierge at 1-888-965-1965 (TTY: 711). If you request a written response to your phone complaint, we’ll respond in writing.

WRITTEN: If you’d like to file a written grievance, please send to one of the following:

Fax: 1-800-845-4104

Mail: HealthTeam Advantage

Attn: Appeals and Grievances Department

300 E. Wendover Ave., Suite 121,

Greensboro, NC 27401

For more information, you can call your HealthTeam Advantage Healthcare Concierge at 1-888-965-1965 (TTY:711).

If you have a complaint, you can complain to Medicare. To submit an online complaint to Medicare, go to https://www.medicare.gov/my/medicare-complaint.

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

Click below to view the Medicare Fact Sheet.

More about the Medicare Prescription Payment Plan

Is the Medicare Prescription Payment Plan right for you?

The Medicare Prescription Payment Plan was initiated in 2025 to help members that have high prescription drug costs early in the year to spread payments across the full year. Not all members will benefit from this program.

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

Step 1

Does your drug spend exceed the annual maximum out-of-pocket (e.g. $2,000 for 2025) in the first few months of the year or period from which you elect into the Medicare Prescription Payment Plan program?

if YES, proceed to Step 2.

if NO, this program will not likely benefit you – Click Here to understand why

Step 2

Based on your drug expenses exceeding the annual maximum out-of-pocket (e.g. $2,000 for 2025), it may help you to spread your payments out over the year. Let’s look at an example.

Let’s say you have high dollar drug(s) with a cost share of $500 in the first few months of the year (you would have met the annual out-of-pocket in April), by electing into the program at the beginning of the plan year the cost would be spread over the year, with payments as highlighted below.

Ready to Elect into the Medicare Prescription Payment Plan Program?

If you are unsure and want further advice, contact our customer service at 888-965-1965 (TTY: 711)
If you want more information directly from Medicare on this program, Click Here to be redirected to the CMS website information page.
If you are ready to elect into the Medicare Prescription Payment Plan program, follow the link provided below.

Or call our Help Desk at 1-877-812-2779

You may request retroactive election into the Medicare Prescription Payment Program. In order to request a retroactive election, for covered prescription(s) you paid your cost share for, you must meet the following:

You reasonably believe any delay in filling the prescription(s) due to the 24-hour timeframe requirement to process your program election may seriously jeopardize your life, health, or ability to function, and you request retroactive election within 72 hours of the date and time the urgent prescriptions(s) were billed to us at the pharmacy.

Understanding Why the Medicare Prescription Payment Plan is Not Right for Me?

Let’s say you have lower dollar drug(s) with a cost share of in the first months of the year (you would NOT likely meet the annual out-of-pocket), electing in the program will not likely benefit you long-term and could actually cause you to owe more at the end of the plan year.

In Example 2, with an $80.00 monthly cost and if elected into the program in Jan, the same payment of $80 will be billed in the first month but as the total amount owed over the year increases and months left in the year decrease the monthly payment goes up and depending on your specific circumstances, you might not benefit from using this payment option due to the higher payments that start in September.

Still unsure?

If you want to use a calculator where you can include your own specific drugs costs to estimate the payments before you make your decision click the below button.

Estimate your payments

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 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.

Corporate

300 E. Wendover Ave., Suite 121, Greensboro, NC 27401

Local Benefit Center

Walk-Ins Welcome

5815 Samet Dr., Suite 107, High Point, NC 27265

HealthTeam Advantage, a product of Care N’ Care Insurance Company of North Carolina, Inc., is a PPO and HMO Medicare Advantage plan with a Medicare contract.  Enrollment in HealthTeam Advantage depends on contract renewal.

Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Every year, Medicare evaluates plans based on a 5-star rating system.