Optum Rx has asked AlignRx to share its five-minute instructional video on how to bill an M3P claim. We encourage you to watch it as an example of how one PBM is educating pharmacies on M3P billing.

Please Note: Each software vendor displays the M3P approved message codes differently. Contact your specific software vendor for details on where to find your approved message codes.

AlignRx recognizes there has been confusion associated with recognizing eligible/enrolled patients and with claims processing for the Medicare Prescription Payment Plan (M3P).

How to Identify Eligible or Enrolled Patients

Eligible Patients

• During claims processing, pharmacies receive a "Likely to Benefit" message for patients who are not enrolled in the M3P (e.g., Code 056: Beneficiary likely to benefit from the Prescription Payment Plan).
• If the "Likely to Benefit" message appears during adjudication, pharmacies are required to share the "Likely to Benefit" information with the patient, ensuring the patient is aware of the opportunity to enroll in the program.
• Patients who are most likely to benefit incur a cost of $600 or more for a single prescription at the point of sale.

See M3P program details at the end of this communication.

Enrolled Patients

• When processing prescriptions for enrolled Medicare patients, your system should indicate an approved message (e.g., Code 057: Beneficiary participating in Prescription Payment Plan).
• Copays must be submitted to the M3P processor utilizing the secondary or (potentially) tertiary processing information provided during adjudication. Once processed correctly, the claim should result in a $0 patient copay.

The Issue and Confusion

• PBMs are reporting low pharmacy compliance, with M3P claims not being processed for eligible/enrolled patients.
• Each pharmacy software vendor displays M3P messages differently, in various sections of the paid claim response.
• There is no hard-stop on claims, making the M3P notification within the paid claim response easily overlooked.
• Pharmacy staff are unaware where to locate additional M3P processing information.

Pharmacy Action

• Please contact your software vendor to confirm where to find M3P-approved message codes and additional processing information.
• Alert your staff to pay close attention to the:

1. Paid claim response
2. Location of M3P processing information (varies by software vendor)

How Do I Know My Pharmacy Has Been Paid? How Does AlignRx eRecon Support M3P?

By law, M3P payments must be made to the pharmacy within 14 days, aligning with the Medicare Prompt Pay requirement. M3P reimbursements are issued by the primary payor and may be included in the same check as the primary payment.

For AlignRx members utilizing our eRecon reconciliation service, each claim and payment transaction will be captured and reconciled in eRecon as expected. Late or missing M3P payments will be followed up by the eRecon team, just like any other reimbursement.

Example of M3P Reimbursement Displayed in eRecon

• Box 1: After the primary transaction was processed, a $244.25 copay remained.
• Box 2: Both the primary and secondary transactions appear in eRecon. The PCN of “MPPP” and Other Coverage Code (OCC) of “08” indicate an M3P transaction.
• Box 3: Since both payments have been received, no outstanding balance remains.

What is the M3P?

The M3P allows patients to spread medication costs over the calendar year. Instead of paying at the pharmacy, patients enrolled in M3P are billed monthly by their health plan. This program applies to either a Medicare Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug Plan (MA-PD).

• M3P allows Medicare beneficiaries to spread prescription costs over the benefit year. ​
• Patients who are most likely to benefit are those with high deductibles who would have to pay a large out-of-pocket amount at the start of the year.  ​
• Any Medicare beneficiary can enroll in the M3P by contacting their plan during the 2025 plan year.  ​
• Enrolled Medicare beneficiaries pay $0 to the pharmacy for covered Part D drugs. ​
• Pharmacies receive a message in the third-party details when a claim is submitted if the patient is ​“Likely to Benefit” from the M3P. ​
• Once enrolled, the Part D plan sponsors bill program participants monthly for cost sharing they incur while in the program. ​
• If a beneficiary does not pay the plan sponsor bill, the beneficiary is removed from the M3P. ​
• Pharmacies are paid in full by the Part D sponsor in accordance with Part D ​prompt payment requirements. 

Below is an example of spreading the medication cost:

Reminder: Visit the Member Portal for valuable resources.

• Select Medicare Part D from the main menu and choose, "Click here for important changes to Medicare 2025 Part D benefits."
• Select Medicare Part D from the main menu and navigate to the References & Links tab. Click "Medicare Pharmacy Quick Reference 2025."

QUESTIONS? AlignRx Pharmacy Services: 844-ALIGNRX (844-254-4679), option 1