By Trenton Thiede, PharmD, MBA
President at PAAS National®

As part of the Inflation Reduction Act, all Medicare prescription drug plans (Medicare Part D plans) – including both standalone Medicare prescription drug plans and Medicare Advantage (MA) plans with prescription drug coverage - will be required to offer the Medicare Prescription Payment Plans (MPPP or M3P). This option allows patients to manage their copays and deductibles evenly throughout the year, benefiting those facing high drug costs early in the year.



While participation is optional, enrolled patients will have a $0 copay at the pharmacy and will receive a monthly bill from their Part D or Advantage Plan, which features 0% interest and no fees. Patients can choose to enroll or opt out of the program at any time. Enrollment can be completed via phone, mail, or website of their selected Medicare Plan Sponsor. However, if patients fail to pay their bill by the end of the grace period (typically 60 days), they may be automatically opted out. It’s important to note that pharmacies are not responsible for enrolling patients or collecting payments on an M3P bill (nor are pharmacies able to enroll patients).

Starting Jan. 1, 2025, if a prescription copay for a Medicare beneficiary exceeds $600, Plan Sponsors (via CMS directive) will require the pharmacy to provide the patient with the standard “Likely to Benefit” Notice1 (CMS Form 10882). The notification to issue this notice will be sent as an online adjudication response Approved Message Code 056 from the PBM, indicating that the patient is “likely to benefit” from the M3P. Since the patient needs to contact the plan to enroll, it won’t happen real time at the pharmacy counter. If the patient wants to opt in prior to picking up the prescriptions, they will need to return to the pharmacy at a later time once they have successfully enrolled.

Once enrolled, all unsold prescriptions should be reversed and reprocessed to the Part D/MA plan, any secondary payor and then the M3P (i.e., the date of service should be the same for the Part D claim, any secondary payor [when applicable] and the M3P transaction). Prescriptions that were sold before opting in does not need to be submitted to the M3P processor, as the patient has already paid the copay.

If the patient has already opted in but does not have their M3P plan information, pharmacies can retrieve the necessary processing details by adjudicating a claim and checking for Approval Message Code 057. CMS mandates that all PCNs for M3P begin with “MPPP”. Paid claim responses will include M3P processing details in the “Coordination of Benefits/Other Payors” segment of the claim information. Note the M3P processing information will not be found in the E1 eligibility response.

Other things to know:

• Maximum out-of-pocket costs for all Part D plans is now $2000
• The M3P plan will only cover Medicare Part D eligible drugs
• Reimbursement to the pharmacy is the same 14-day timeframe
  
  

PAAS Tips:

• Make sure that the “Likely to Benefit” Notice1 (CMS Form 10882) is being handed out every time there is an Approved Message Code 056
  
• LTC pharmacies are not exempt from distribution, although they may do so in the usual billing cycle
  
• Pharmacies should be prepared for onsite auditors to ask for the form and the pharmacy’s policy for distributing.
  
• PAAS FWA/HIPAA compliance members have an update to their Policy and Procedure manual pushed out at the end of the year to reflect a new policy
  
• If a prescription is not picked up, pharmacies must reverse both the Part D and M3P claims

References:

https://www.cms.gov/medicare/regulations-guidance/legislation/paperwork-reduction-act-1995/pra-listing/cms-10882

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