Medicare Prescription Payment Plan

In August 2022, President Biden signed the Inflation Reduction Act of 2022 (P.L. 117-169) into law. The Inflation Reduction Act aims to improve Medicare by expanding benefits, lowering drug costs, and improving the sustainability of the Medicare program for generations to come.
 
Starting January 1, 2025, the Medicare Prescription Payment Plan is a new program required under the Inflation Reduction Act, under which Part D sponsors 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.
 
Highlights:

1. New Out-of-Pocket Cost Limit
   • Patients will pay no more than $2,000 annually for all brand-name and generic prescriptions.
2. Medicare Prescription Payment Plan (MPPP)
   • Optional program allowing patients to spread prescription costs over the year.
   • Patients enroll directly through their Medicare plan, not at the pharmacy.
   • Enrolled patients pay $0 at the pharmacy counter for covered Part D drugs; pharmacies will be reimbursed by Medicare Part D plans.

Key Points for Pharmacists:

• You'll be notified by Part D Sponsor if a patient is not enrolled and has a single Rx cost of $600 or more.
• You must provide these patients with the "Medicare Prescription Payment Plan Likely to Benefit Notice."
  • Download HERE.
• Unique BINs/PCNs beginning with "MPPP" will be used for processing payments.
• Reimbursement will be received within 14 days for electronic claims.

Patient Counseling Tips:

• Explain that MPPP enrollment is optional and done through their Medicare plan.
• Highlight that the program may benefit those with high early-year costs or who take specialty medications.
• Remind patients they can opt-out at any time.

Pharmacy Process Changes:

• Submit claims using the Unique MPPP BIN/PCN for enrolled patients.
• Process any other health insurance before billing MPPP.
• Reverse and reprocess eligible claims for new MPPP participants.

Additional Resources:

• **Infographic: Medicare Prescription Payment Plan (Credit: PSW/NASPA)
• CMS: Medicare Prescription Payment Plan
• Fact Sheet: Medicare Prescription Payment Plan (CMS)
• Medicare: What’s the Medicare Prescription Payment Plan?
• Fact Sheet: What’s the Medicare Prescription Payment Plan? (Medicare)
  • For Patients:
    • Medicare: What to know before participating
    • Medicare: Will this payment option help me
    • Medicare: What to know if I'm participating