CMS-10882 Part D Sponsor Notice of Voluntary Removal from the Medi

Exhibit 6 - Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan

[Instructions: ‘The Notice of Voluntary Removal’ is an official plan document that lets a participant know they’re no longer participating in the payment option. The notice describes the process for rejoining the program in the future and details other programs that can help lower costs, like Extra Help.

This model notice satisfies the requirement for Part D sponsors to send participants a confirmation of voluntary removal and meets all the communication requirements outlined in Section 30.3 of the “Medicare Prescription Payment Plan: Final Part Two Guidance on Select Topics, Implementation of Section 1860D-2 of the Social Security Act for 2025, and Response to Relevant Comments.” 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 form. Use as applicable.]

[Part D sponsors may insert a title for the notice, such as “You’re no longer participating in the Medicare Prescription Payment Plan through [plan sponsor]”]

[Member #]

[Date]

[Part D sponsors may include the following four elements:

[RxID]

[RxGroup]

[RxBin]

[RxPCN]]

Dear [Member],

Starting [insert effective date], you’re no longer participating in the Medicare Prescription Payment Plan through [plan sponsor], and you’ll pay the pharmacy directly for your new out-of-pocket drug costs.

[Plans may choose to use Option 1 to send to all enrollees voluntarily terminating from the program OR may tailor the notice to the reason for voluntary termination with either Option 2 or Option 3.]

[Option 1 (provide to all enrollees, regardless of the reason for voluntary termination): You’re getting this letter because you either asked to stop participating in this payment option, or you changed your Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan). This letter only applies to your participation in the Medicare Prescription Payment Plan. If you joined a new plan, and you’d like to participate in the Medicare Prescription Payment Plan again, contact your new plan.]

[Option 2 (termination from program only): You’re getting this letter because you asked to stop participating in the Medicare Prescription Payment Plan. 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].]

[Option 3 (disenrollment from Part D plan and termination from program): You’re getting this letter because you disenrolled from [plan name], which automatically ends your participation in the Medicare Prescription Payment Plan. If you joined a new plan, and you’d like to participate in the Medicare Prescription Payment Plan again, contact your new plan.]

You’re required to pay the amount you owe, but you won’t pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly. Contact [plan name] if you have questions about paying your balance.

Can I use this payment option in the future?

[Plans may choose to use Option 1 to send to all enrollees voluntarily terminating from the program OR may tailor the notice to the reason for voluntary termination with either Option 2 or Option 3.]

[Option 1 (provide to all enrollees, regardless of the reason for voluntary termination):

• If you’re still in [plan name]: Yes. Visit [insert PDP webpage where the application is], or call us at [phone number], [days and hours of operation]. TTY users can call [TTY number].

If you’re joining a new plan: Yes. All Medicare drug plans and Medicare health plans with drug coverage offer this payment option.

[Option 2 (termination from program only):

Yes. Visit [insert PDP webpage where the application is], or call us at [phone number], [days and hours of operation]. TTY users can call [TTY number].]

[Option 3 (disenrollment from Part D plan and termination from program):

Yes. All Medicare drug plans and Medicare health plans with drug coverage offer this payment option. Contact your new plan if you’d like to participate in the Medicare Prescription Payment Plan again.]

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 costs. 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/medicare-savings-programs to learn more.

• 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 might 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.]

2