Medicare Prescription Payment Plan Case Studies

Case Study #1: Individual diagnosed with lung cancer in May; would benefit from enrolling in the MPPP

Kayla did not join the MPPP during Open Enrollment because typically she only pays $1.56/month for a daily pill to help keep her cholesterol in check. But in June, she is diagnosed with metastatic non-small cell lung cancer.

Her Part D plans covers her new medication at a cost of $1,9992.20/month. When Kayla goes to get her new treatment, the pharmacy tells her about the MPPP and she decides to immediately enroll. She reaches the $2,000 out-of-pocket limit in June, so while she continues to receive her medications in July - December, she doesn't incur any more out-of-pocket costs. Since she opted into the MPPP, Kayla can spread the high out-of-pocket costs over the rest of the year. 

Case Study #2: Individual living with exercise-induced asthma; would not benefit from enrolling in MPPP

Tim has exercise-induced asthma and uses a quick-relief inhaler.  Tim recently turned 65 and on his new Medicare Part D plan, his inhaler costs him $49.98. He needs about two inhalers per year to accommodate how often he exercises. Tim also pays $10 a month for a statin. Tim opted to not join the MPPP as his monthly out-of-pocket costs are predictable and low and will remain well below the $2000 out-of-pocket cap. Because Tim is enrolled in Medicare, the cap on some rescue inhalers does not apply. 

Case study #3: Individual living with COPD; not likely to benefit from enrolling in the MPPP

Susan lives with COPD and high blood cholesterol. Susan reads the information about the new MPPP but is not sure if it’s right for her. The medication Susan uses to control her COPD costs her $136/month and her statin is $10/month. If Susan enrolls in the MPPP, her monthly out-of-pocket costs at the beginning of the year would be lower, but she would have to make up for it and would have much higher monthly costs at the end of the year. See the table below for why Susan may not want to enroll in the MPPP.

Case study #4: Individual living with persistent asthma; would benefit from enrolling in the MPPP

Vanessa enrolls in the MPPP because she lives with persistent asthma and two other conditions which require medications under Part D. Vanessa fills prescriptions for her long-term controller medicine and other medications every month totaling $456/month. In January, she also pays an additional $49.98 for her quick-relief inhaler, which she only needs to fill once per year.  Vanessa reaches the $2,000 out-of-pocket maximum for 2025 in May, meaning she does not incur any new out-of-pocket costs from June-December, but she is able to continue to spread out her high payments from the beginning of the year.