With the changing environment in health care, the Medicare Prescription Payment Plan is a new program created under the Inflation Reduction Act, which began January 1, 2025.

Thank you for choosing Keystone First VIP Choice (HMO-SNP) as your health care provider. We are committed to the success of your treatment and care. Payment for services provided is a part of the Medicare Prescription Payment Plan. Keystone First VIP Choice must provide enrollees the option to pay out-of-pocket prescription drug costs in the form of monthly payments over the course of the plan year, instead of all at once at the pharmacy.

Per the billing terms and conditions: Plan members are responsible for making the necessary payments toward covered Part D drug cost sharing you incur while in the Medicare Prescription Payment Plan program. Program participants will pay $0 to the pharmacy for covered Part D drugs, and Keystone First VIP Choice will then bill program participants monthly for any cost sharing they incur while in the program. Pharmacies will be paid in full by Keystone First VIP Choice in accordance with Part D prompt payment requirements.

Keystone First VIP Choice is offering Plan members this opportunity to set up a payment plan for the prescriptions you will receive. This payment plan agreement authorizes Keystone First VIP Choice to bill members based on the information on file as a method to collect payment for the services provided.

Each month, Keystone First VIP Choice will send you a bill with the amount you owe for your prescriptions, when it is due, and information on how to make a payment. You will get a reminder from Keystone First VIP Choice if you miss a payment and will be allowed a 60 day grace period to pay any past due payments.

If you do not pay your bill by the date listed in that reminder, you will be removed from the Medicare Prescription Payment Plan. You will have an opportunity to dispute the cancellation of your participation in the payment plan if there is a "good cause" reason for not paying your monthly bill. Call your plan if you think Keystone First VIP Choice made a mistake about your Medicare Prescription Payment Plan bill or cancellation of your Medicare Prescription Payment Plan. You will have an opportunity to file a grievance pertaining to the cancellation of your participation. The grievance process can be found in your Evidence of Coverage (PDF).

You are required to pay the amount you owe, but you will not pay any interest or fees, even if your payment is late. If you are removed from the Medicare Prescription Payment Plan, you will still be enrolled in your Medicare health or drug plan.

Leaving won't affect your Medicare drug coverage and other Medicare benefits. Keep in mind:

• If you still owe a balance, you're required to pay the amount you owe, even though you are no longer participating in this payment option.
• You can choose to pay your balance all at once or be billed monthly.
• You will pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.

If your payment is not received by the due date on the invoice, you may receive notification of cancellation from the Medicare Prescription Payment Plan program.

For payments toward your balance, you are expected to:

• Make the payments as agreed upon without default.
• Make payments until the outstanding balance in your account is zero dollars ($0).

For your convenience, Keystone First VIP Choice offers this payment plan with no finance or interest charges. If we receive the periodic payments set forth in this agreement, Keystone First VIP Choice shall not pursue any additional collection actions on your account. If you still owe a balance that roles over to a new calendar year you will still be required to make that payment.

Signing the Medicare Prescription Payment Plan participation request form shall be considered binding of this Billing Terms and Conditions.

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