Document 2 - Clinic Staff Education (2026)
Detailed guidance for staff education and patient counseling.
Print this page for training.
Purpose of this document
This document is for clinic staff education. It explains what the Medicare Prescription Payment Plan is, who it helps, and how staff should discuss it with patients.
What the Medicare Prescription Payment Plan is
The Medicare Prescription Payment Plan is a voluntary payment option offered by all Medicare drug plans and Medicare health plans with drug coverage.
It allows patients to spread out-of-pocket costs for covered Medicare prescription drugs across the calendar year, instead of paying large amounts at the pharmacy early in the year.
It does not reduce the total yearly cost of medications. It only changes when and how patients pay.
Key 2026 facts staff should know
- Maximum Part D deductible in 2026 is $615
- Annual out-of-pocket maximum for covered Part D drugs in 2026 is $2,100
- After reaching the out-of-pocket maximum, patients do not pay out-of-pocket for covered Part D drugs for the rest of the calendar year
- There is no cost to enroll in the payment plan
What changes for the patient if they enroll
- The patient keeps their Medicare drug coverage
- The patient continues to pay any monthly plan premium
- For covered Part D drugs, the patient usually does not pay the pharmacy
- The Medicare drug plan sends the patient a monthly bill
- Monthly bills can change if medications change
When staff should consider mentioning this option
- Patient reports high prescription costs
- Patient delays or skips medications due to pharmacy cost
- Patient reaches the pharmacy and cannot afford payment
- Patient expresses concern about large early-year medication costs
When the option may be less helpful
- Low yearly prescription costs
- Prescription costs are consistent each month
- Enrollment late in the year, especially after September
- Patient already receives assistance that lowers drug costs, such as Extra Help
Enrollment guidance for staff
- Enrollees request participation through their Medicare drug plan by phone, paper, or the plan's website
- The plan sponsor processes the election
- Staff should encourage patients to use the exact phrase: "I want to enroll in the Medicare Prescription Payment Plan"
- Medicare drug plans are required by law to offer this program and help patients enroll
Pharmacy role clarification
- Pharmacies may provide the CMS likely-to-benefit notice and direct an enrollee to the plan
- The plan sponsor processes the participation request
If the patient has difficulty enrolling
If a patient or family reports barriers or conflicting information, direct them to the number on the Medicare drug plan membership card or to 1-800-MEDICARE at 1-800-633-4227.
The patient always remains the decision maker.