Exhibit 4_Notice of Failure to Pay_2025 - Track Change

Exhibit 4 – Part D Sponsor Notice for Failure to Make Payments under the Medicare
Prescription Payment Plan
[Instructions: The ‘Notice for Failure to Make Payments’ notifies a participant that a payment
has not been received for the billed amount. The notice gives the participant instructions on how
to submit their payment during the grace period. It also clarifies that if payment is not received,
the participant will be removed from the payment option; and explains that there are assistance
programs (e.g., Extra Help) that can lower costs.
This model notice satisfies the requirement for Part D sponsors to notify participants when they
haven’t paid a monthly billed amount and meets all the communication requirements outlined in
at 42 CFR § 423.137(f). Plan sponsors may add their logos to brand this document.
The italicized blue text in square brackets is information for the plans and shouldn’t be included
in the request form. The non-italicized blue text in square brackets may be inserted or used as
replacement text in the request formnotice. Use as applicable.]
[Part D sponsors may insert a title for the notice, such as “Reminder: Pay your Medicare
Prescription Payment Plan bill”]
[Member #]
[Date]
[Part D sponsors may include these additional fields:
[RxID]
[RxGroup]
[RxBin]
[RxPCN]]
Dear [Member]:
We didn’t get your monthly payment for the Medicare Prescription Payment Plan that was due [payment
due date]. To stay in the Medicare Prescription Payment Plan, you must pay [insert the full amount or a
partial amount(s) should the plan choose to allow enrollees to pay the balance over separate payments]
by [insert date for the end of the grace period (i.e., the date that is two calendar months from the first day
of the month following the date on which this notice is sent)]. Remember, you started using this payment
option on [date effective] to help manage your out-of-pocket Medicare Part D drug costs for drugs
covered by your plan by spreading them across the calendar year (January – December).
This letter only applies to your participation in the Medicare Prescription Payment Plan. Your
Medicare drug coverage and other Medicare benefits won’t be affected, and you’ll continue to be
enrolled in [plan name] for your drug coverage.

How do I pay my bill?
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[Plans may tailor payment options based on which payment methods are available. They may also add a
mailing address for payments made through the mail, by check.]
You owe [unpaid amount]. You can pay:
• Online at [plan’s website], by credit/debit card.
• Through the mail, by check.
• [insert other payment methods offered by the plan like electronic funds transfer (including
automatic charges of an account at a financial institution or credit or debit card account)].
If you have questions about your payment, call us at [phone number], [days and hours of operation]. TTY
users can call [TTY number].

What happens if I don’t pay my bill?

If you don’t pay your bill by [effective date], you’ll be removed from the Medicare Prescription Payment
Plan through [plan sponsor], and you’ll pay the pharmacy directly for new out-of-pocket drug costs.
You’re required to pay the amount you owe, but you won’t pay any interest or fees, even if your payment
is late.
As long as you continue to pay your plan premium (if you have one), you’ll still have drug coverage
through [plan name].

What if I think there’s been a mistake?

If you think that we’ve made a mistake, call us at [phone number]. You also have the right to follow the
grievance process found in your [insert “Member Handbook” or “Evidence of Coverage,” as
appropriate. Plans may also include language explaining where enrollees can find these documents].

What if I can’t afford to pay both my plan premium and my Medicare
Prescription Payment Plan payment?

Always pay your [plan name] premium first. See below for more information on programs that can help
lower your costs.

What programs can help lower my costs?

[Plans may add their plan-specific assistance programs, if applicable. If any of these programs are not
available to a plan’s enrollees, they may be removed. In areas where Extra Help isn’t available, plans
have the option to include the following language: “Extra Help isn't available in Puerto Rico, the U.S.
Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. But there are other programs
available in those areas that may help lower your costs. Call your State Medical Assistance (Medicaid)
office to learn more.”]
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. 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/medicaresavings-programs to learn more.

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State Pharmaceutical Assistance Programs (SPAPs): Programs that may 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’s 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/.
Note: The programs listed above may help lower your costs, but they can’t help you pay off your
Medicare Prescription Payment Plan balance.
[Plans may insert link to their Medicare Prescription Payment Plan website or customer service phone
number for additional information.]

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