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Here are a few examples of how payments might be calculated using the Medicare Prescription Payment Plan
Mary opts into the Medicare Prescription Payment Plan in January 2025. She fills a high-cost prescription at the pharmacy in that month. Her OOP cost sharing for this prescription is $1,200.
Since there are 12 months remaining in the plan year, her cost is divided by 12. $1,200/12 = $100.
If Mary continued to have no new covered Part D prescription drug costs in 2025, her monthly payment would be $100 for all the months remaining in the plan year, as shown below:
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
$1,200
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$1,200
$100
$100
$100
$100
$100
$100
$100
$100
$100
$100
$100
$100
$1,200
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
$4.00
$1,996.00
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
$2,000.00
$4.00
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$181.45
$2,000.00
In January, Joe fills a prescription that costs him $4.
In February, Joe refills his high-cost maintenance drug, with a cost of $2,534. Joe has now surpassed the 2025 OOP maximum of $2,000. $2,000 is the most Joe will pay in 2025.
$2,000 - $4 (what Joe paid in January) = $1,996. $1,996/11 (the number of months remaining in 2025, including February) = $181.45
Since Joe has already met the annual out-of-pocket maximum, he will have no new additional costs for 2025, regardless of what his prescription drug costs are.
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
$4.00
$4.00
$4.00
$617.00
$4.00
$4.00
$124.00
$4.00
$4.00
$124.00
$4.00
$4.00
$901.00
$4.00*
$4.00*
$4.00*
$220.89
$50.01
$50.59
$71.25
$72.05
$73.05
$114.39
$116.39
$$120.38
$901.00
Prior to April, Shawna fills low-cost monthly maintenance drugs ($4).
In April, Shawna opts into the payment plan before filling a new prescription for a 90-day supply that costs $617.
The maximum monthly cap (meaning the most she can be billed) for the first month (April) in which the Medicare Prescription Payment Plan is effective for Shawna is:
$2,000 (the OOP max in 2025) - $12.00 (what she paid in the first 3 months) / 9 (number of months left in 2025) = $220.89
Because her drug cost ($617) is more than the monthly cap ($220.89), she is only billed the monthly cap.
In May 2025, Shawna refills only her existing generic maintenance drug ($4).
Since Shawna’s costs were $617 in April and she was billed $220.89, her remaining balance is $396.11. Since she paid $4 more in May, her monthly payment in May is: ($396.11+$4.00)/8 = $50.01
If Jane continues this pattern of monthly fills ($4 copay) and 90-day fills (now a $120 copay, because she met her plan deductible in April), here’s what her monthly payments would look like:
*These payments were made directly to the pharmacy, outside of the Medicare Prescription Payment Plan.
As you can see, monthly payments vary by what you pay and when you fill your prescriptions. Use our monthly payment estimator to estimate your monthly payments if you know approximately how much you expect to pay, and in which months, in 2025.
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