Maximum Monthly Cap on Cost-Sharing Payments Under Prescription Drug Plans: Draft Part One Guidance on Select Topics, Implementation of Section 1860D-2 of the Social Security Act for 2025, and Solicitation of Comments

Relevant to: Interested Parties

The purpose of this document is to provide interested parties with draft part one guidance on a select set of topics for the Maximum Monthly Cap on Cost-Sharing Payments Program, which was established by section 11202 of the Inflation Reduction Act (IRA) (P.L. 117-169) and signed into law on August 16, 2022. The IRA makes Medicare stronger for current and future enrollees. It makes health care more accessible, equitable, and affordable. Section 1860D-2(b)(2)(E) of the Social Security Act (the Act), as added by section 11202 of the IRA, requires all Medicare prescription drug plans to offer their Part D enrollees the option to pay their out-of-pocket (OOP) Part D drug costs through monthly payments over the course of the plan year instead of as upfront payments at the pharmacy point of sale (POS) beginning January 1, 2025. This provision applies to all Part D sponsors,1, 2 including both stand-alone Medicare prescription drug plans (PDPs) and Medicare Advantage (MA) plans with prescription drug coverage (MA-PDs), as well as Employer Group Waiver Plans (EGWPs), cost plans, and demonstration plans. This guidance document will be followed by a second round of guidance, set to be released by early 2024.

See the full guidance for more information.