Apparently, this is something new that the Feds/CMS has implemented with Medicare Part D and Medicare -C ( Advantage). According to this article, it appears that the various PBM ( Prescription Benefit Managers) have not done much in educating Pharmacists/Pharmacies on how this is supposed to be handled in the billing of the pt’s prescriptions to the PBM on the pharmacy computer system. According to the article the PBM’s customer service staff was not well trained either with the exception of training the CS staff to use this opportunity with the pt to try to get the pt to switch their Rxs to the PBM’s mail-order pharmacy. A quote from Obama’s first chief of staff seems to apply here “You never want a serious crisis to go to waste. And what I mean by that [is] it’s an opportunity to do things that you think you could not before”
what is MPPP in the Medicare Part D program?
The Medicare Prescription Payment Plan (MPPP) is a new program set to begin in 2025 as part of the Medicare Part D prescription drug coverage. This optional program allows beneficiaries to spread out their out-of-pocket prescription drug costs over the course of the plan year, rather than paying the full amount at the pharmacy when picking up medications12.
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Available to all Medicare Part D enrollees, including those in Medicare Advantage plans with prescription drug coverage13
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Enrollment possible during Medicare Open Enrollment (October 15 – December 7, 2024) or anytime throughout the plan year1
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Beneficiaries pay $0 at the pharmacy counter for covered Part D drugs13
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Monthly bills from the Part D plan cover out-of-pocket costs, spread over the year13
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Does not reduce total annual cost-sharing, only smooths payments over time2
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Helps manage high out-of-pocket costs, especially early in the plan year15
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Particularly beneficial for those expecting to reach the $2,000 out-of-pocket cap before December 13
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Enrollees with high out-of-pocket costs early in the plan year15
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Those facing OOP costs of $600 or more for a single medication25
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Beneficiaries with low, stable out-of-pocket drug costs2
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Those receiving cost-sharing assistance from programs like Extra Help, SPAP, or MSP2
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Two-month grace period for missed payments2
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Failure to pay may result in removal from MPPP and ineligibility for future enrollment25
It’s important to note that while the MPPP can help spread out costs, it does not lower the total annual cost-sharing for prescription drugs. Beneficiaries should carefully consider their individual circumstances and consult with their healthcare providers or Medicare counselors to determine if the MPPP is right for them5.
Citations:
- https://www.lung.org/getmedia/d10aa01a-efcc-4daf-88e2-5bb2298574a5/MedicarePrescriptionPaymentPlan_Infographic.pdf
- https://targethiv.org/library/faqs-medicare-prescription-payment-plan
- https://www.lung.org/policy-advocacy/healthcare-lung-disease/healthcare-policy/medicare/prescription
- https://www.mintz.com/insights-center/viewpoints/2146/2025-02-13-operationalizing-medicare-prescription-payment-plan-and
- https://avalere.com/insights/navigating-the-medicare-prescription-payment-plan-what-it-means-for-patients-and-patient-groups
- https://www.lls.org/article/get-informed-important-changes-medicare-part-d
- https://www.medicarerights.org/medicare-watch/2024/07/25/guidance-on-inflation-reduction-acts-medicare-prescription-payment-plan-released
- https://www.lungevity.org/blogs/what-you-need-to-know-about-changes-to-medicare-part-d-in-2025
- https://www.sanfordhealthplan.com/align/pharmacy-and-drug-coverage/medicare-prescription-payment-plan
- https://www.panfoundation.org/understanding-the-medicare-prescription-payment-plan/
- https://www.cms.gov/inflation-reduction-act-and-medicare/part-d-improvements/medicare-prescription-payment-plan
- https://www.medicare.gov/prescription-payment-plan
- https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf
- https://www.cms.gov/files/document/faqs-related-medicare-prescription-payment-plan.pdf
- https://www.humana.com/pharmacy/patient-assistance/medicare-prescription-payment-plan
- https://www.medicare.gov/prescription-payment-plan/before-payment-option
- https://avalere.com/insights/navigating-the-medicare-prescription-payment-plan-what-it-means-for-part-d-plan-sponsors
Answer from Perplexity: pplx.ai/share
PBMs warn of low compliance for Part D claims with certain MPPP BIN/PCNs
https://ncpa.org/newsroom/qam/2025/02/20/pbms-warn-low-compliance-part-d-claims-certain-mppp-binpcns
PBMs processing Medicare Part D claims have reached out to NCPA reporting low compliance for claims to the BIN/PCN that start with “MPPP…” when a patient is participating in the Medicare Prescription Payment Plan. If your pharmacy receives paid claim responses from Medicare Part D plans with Approved Message Code 057 Beneficiary participating in Prescription Payment Plan, you absolutely need to send a subsequent claim for the copay amount due to the Part D plan’s MPPP processor.
Patients may need additional information about the new program. Once they participate, all copays must be submitted to the MPPP processor. Patients who no longer wish to participate should contact their plan. Contact your pharmacy management system right away if you don’t know how to check for Approved Message Code 057, or where to look to find the MPPP processing information in the COB/Other Payer segment. For more information on the MPPP, including a continuing education program for pharmacists and pharmacy technicians, go to https://ncpa.org/medicare.
NCPA has also heard from members that Part D plan member hotlines are providing confusing information about MPPP and are also using the encounter to steer patients into mail order from an affiliated mail-order pharmacy.
Click here for tips on making formal complaints to Medicare.
Filed under: General Problems
So is it just me or does anyone else find it striking that someone would have to set up a payment plan to get their meds?