January 16, 2025 • 13 mins
In this episode, APhA Executive Education Fellow, Nick, APhA's Sr. Manager of Educational Activities, Maya and Katie Meyer will review recent updates to Medicare that occurred beginning 2025 because of the inflation reduction act. These include an updated out-of-pocket maximum for Medicare beneficiaries and the Medicare Prescription Payment Plan, a new option to help patients manage their prescription drug costs.
Each month, APhA will release two, 10 to 15 minute podcast episodes offering a fresh dose of education highlights, practice pearls, and insights to inform your pharmacy practice and advance patient care. Listen to new episodes at your convenience! Both members and nonmembers can log into their APhA Learning Library account to successfully complete a short assessment at the end of each month to earn 0.5 hours of CE credits (.05 CEU).
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Disclaimer: The content is intended for informational purposes only and should not be considered or taken as medical advice. The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of any entities they represent or its employees.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
Welcome to the First Fill and Happy New Year!
As we move into 2025, this monthwe wanted to be sure to highlight
some new updates to Medicare that are happeningright now due to the Inflation Reduction Act.
If you're serving patients out in the community,you're likely
getting questionsabout the Medicare prescription payment plan.
And we are here to provide you with answers.
(00:25):
I'll also mention that if you visit our billingand payments center on pharmacist.com,
we've created a one page resource with supportfrom Johnson and Johnson for you to use
to help educate your patientsabout the Medicare prescription payment plan.
Definitely check it outand I hope that you find it extremely helpful.
Before we dive in today,I'd like to introduce my guests,
APhA Executive fellow, Nick and APhA
(00:47):
Education Team's newest team member, Maya.
Nick and Maya, why don't you introduce yourselves?
Hey, everyone.
I'm Nick, and as Katie said, I'm the executivefellow here with education this year.
Happy to be here and excited to get started.
Hello. Hello.
My name is Maya Harris.
You may remember meas one of the education fellows last year.
(01:09):
I now serve as Senior Managerof educational activities
here at APhA and I am happy to be back.
All right.
We're glad to have you both.
Thanks so much, Nick and Maya.
Let's dive in.
Before we get into the detailsof the Medicare prescription payment plan,
I wanted to talk through just a few other relevantupdates to Medicare that have occurred recently
(01:30):
due to the Inflation Reduction Act,which was originally signed into law in 2022.
First, Medicare beneficiaries
now have insulin available at $35 per monthper covered prescription.
They also have access to recommendedadult vaccines at zero cost.
New for 2025, the out-of-pocket
(01:51):
prescription drug cost is now capped at $2,000.
Once patients meet that out-of-pocket maximum,
they will no longer incur costsfor their prescription drugs.
In addition to
these benefits, such as lower costsprescription drugs,
Medicare is now able to negotiatedirectly with drug manufacturers
to lower the price of some of the costliestsingle source brand name part B and D drugs,
(02:16):
enabling increased access to innovative
lifesaving treatments at lower costs.
Throughout the past quarter,HHS has announced cost savings
for a total of 118 Part B prescription drugs.
Most recently on December28, 64 drugs were added to the list,
including lifesaving medications for substance use disorder,
(02:37):
large B-cell lymphoma and more.
One other update that's brandnew for 2025 is the Medicare prescription
payment program that's very relevantfor our community pharmacy practitioners
as it has implicationsfor billing as well as questions for patients.
We wanted to dive into more of thisspecifically today to help listeners understand
(02:59):
the benefit and also answer some questionsthat may come your way.
Next week, I'll talk to a community pharmacypractitioner who will share her experience
navigating the Medicare prescriptionpayment plan so far in 2025.
So this brings me to my first question, Maya.
What exactly is the Medicare prescriptionpayment plan
(03:19):
and how can it benefit our patients?
Sure, Katie.
The Medicare prescription payment plan, also known
as M3P, is a programthat allows Medicare beneficiaries
to spread out the cost of their prescription drugsover the course of the year.
Older adults enrolled at Medicare are eligible
(03:39):
if they have a Medicare PartD prescription plan, either standalone
Part D, or coveragethat is part of a Medicare Advantage plan.
And so when thinking about how this works,it's important to remember the additional update
for 2025, which is the $2,000
out-of-pocket maximum for Medicare prescriptiondrug costs.
(04:01):
So in thinking about that, for a patient
who would typically reach their $20 maximumin January all at once
when rolls would no longer pay $2,000 in January,
but $166.67 monthly throughout the year.
So essentially, the plan helps Medicare
beneficiaries spread the cost at their medicationsthroughout the entire year
(04:26):
rather than having high cost earlier in the year.
Thanks, Maya.
When you're talking about it,it kind of reminds me of my gas bill, right?
How I pay a million dollars(exagerrating of course), in the winter
to heat my house and then much less in the summer,
I think my utility companyactually offers a plan similar to this.
Maybe I should look into it.
(04:46):
All right.
Got a little bit off track there for a minute.
Sorry about that.
So, Nick, can you tell listenerswhat patients would benefit
most from therapy if there are any restrictionsfor patient enrollment?
And then what patients can expectafter they enroll and therapy?
Yeah, of course, Katie.
(05:06):
So thinking about how the plan works, the patientswe should be suggesting the plan
to are those that are taking either oneor multiple costly medications and have difficulty
paying for their medication costsall at once or earlier in the year.
Patients that have generally low medication costsreally won't see a benefit
as they likely won't even meet that $2,000out of pocket maximum throughout the year.
(05:29):
As you mentioned before, patientswith the general Medicare Part D plan
or Medicare Part D through a Medicare Advantageplans
are eligible to enrolland it isn't active enrollment.
So they have to go and do it themselves.
Patients who receive extra helpor other financial assistance
for their medicationsdo not qualify for the program.
The program does not reducethe cost of a patient's medications.
(05:51):
It simply spreads them out throughout the year.
For patientswho have trouble paying for their medications
and are looking to reduce their costs,it's prudent
to suggest that they look into the extra helpprogram to see if they qualify.
An area of potential confusionis that enrollment cannot be done in the pharmacy
in order to enrollpatient needs to contact their Medicare plan
(06:12):
to let them know that they would like to enrollafter contacting the Medicare plan.
It typically takes about 24 hoursto process the enrollment.
Once they're enrolled,they will pay a $0 copay at the pharmacy
and receive a separate billfrom their Medicare plan each month.
Again,
after contacting their plan,it takes about 24 hours for them to get set up,
(06:32):
so they may need to waitto pick up their medications
if they're expecting that $0 co-payat the pharmacy after they enroll in the program.
They will also receive a program overviewfrom their plan that includes the effective date
of their participationand examples of their maximum
monthly out-of-pocket costsbased on their current medication regimen.
These costs change based on new prescriptionsthat they receive and other factors
(06:53):
like when they enroll.
Basically,if patients would benefit from the program, it's
best for themto enroll as early in the year as possible.
So the cost is spread out as evenly as possible.
Awesome. Thanks, Nick.
So, Maya, let's shift gears a little bit
to the pharmaciesresponsibilities related to that program.
Can you tell listeners a little bitabout what pharmacies should be doing?
(07:15):
Ofcourse Katie,
one important detailthat was written into the Inflation Reduction
Act is in the section titled Targeted Part
D Enrollee Notification at Point of Sale.
And in this section, the CMS states
that Part D sponsors and pharmacies must use
(07:35):
a $600 single prescription POS threshold
to identify enrolleeslikely to benefit from the M3P.
Now, this approach helps to identify individuals
with a very highlikelihood of benefiting from M3P.
When this occurs,the pharmacies should provide the patient
(07:55):
with the Medicare prescription payment planlikely to benefit notice
either in paper format or via phonethat they may benefit from the program.
So a few key points to communicatewith your patients.
They must enroll directlythrough their Medicare plan
and cannot enroll at the pharmacyonce their plan is active.
(08:17):
They'll be able to pay $0 for their prescriptions
at the pharmacyand receive a monthly bill from their plan.
If they have questions about what their monthly
payment will be based onthe current list of medications.
They should contact their plan.
You might
also be wondering howbilling and reimbursement works.
(08:37):
So once the patients are enrolledafter waiting 24 hours for the plan to be active,
the pharmacy will begin to use the PIN or PCN
that begins with MPPP.
If you submit a claim to their current plan,you'll receive the M3P bin
and PCN from the plan electronically.
(08:58):
After submitting a claim using the MPPP
and PCN you will receive a paid response
reflecting the prescription drug plan and patient
responsibility amounts for electronic claims.
You will receive reimbursement from Medicare planswithin 14 days.
Now, the reimbursement will take 30 days
(09:19):
for any claimsthat are not submitted electronically.
This is a very important pointthat I want to enforce.
We actually ran a survey latelast year and pharmacies
were concerned about reimbursement with the M3P.
Now, rest assured,you will be reimbursed by the plan
either electronically within 14 daysor within 30 days for other claims.
(09:45):
Great.
Thanks so much for that, Maya.
Before we wrap up today, Nick,in talking through this,
we thought of a few questions that we felt thatpharmacies and pharmacy technicians might get.
Can you review those and the answersto the questions with our listeners?
Yes, sure, Katie.
First, patients are likely to ask abouthow much their costs will be.
(10:06):
And while they'll pay $0 at the pharmacy,their monthly cost
will vary depending on their currentand future medication list when they enroll, etc..
Your best bet as a pharmacist or pharmacytechnician is to refer them to their plan.
For more information about whattheir monthly bill is going to look like,
you can reinforce a new out-of-pocketmaximum of $2,000
(10:26):
so that they will payno more than that amount in 2025.
Patients may
also ask if it matters what pharmacy they go toif they enroll.
The costs for their prescriptions
are probably going to vary on whethertheir selected pharmacy is in or out of network
or if they're using a mailer serviceor another type of pharmacy,
just as they would if they were not using the M3P.
(10:47):
Patients can contact their Medicare planto see if they need
help decidingwhich pharmacy to use for the lowest cost.
As a reminder, though, once enrolled in the plan,
they will pay nothing at the pharmacyand be billed by their plan monthly.
If patients askedwhat happens if they miss a monthly payment,
the answer should be deferred to their planwill then inform them of next steps.
(11:08):
if a payment is missed.
And lastly, if patients are lookingfor additional resources or other information,
they can visit their Medicare plan's websiteor call them for more information.
If they need help contacting their plan,they should call 1-800-MEDICARE.
So M-E-D-I-C-A-R-E.
You can also provide themwith the one pager that we created that's
(11:29):
available on the billing center on pharmacist.com.
It does a really nice jobof breaking everything down
and answeringsome of these frequently asked questions.
Awesome.
Thanks so much Nick and Maya for joining me todayand providing these important
updates about Medicare for pharmacy professionals.
So just to summarize, major takeaways in 2025,the maximum
(11:50):
out-of-pocket prescription drug costs for patientsenrolled in
Medicare is now $2,000.
The medication prescription payment planor M3P, is a new option
to help patients with budgeting which helps themto spread their costs across the full year
instead of paying higher amountsin the beginning of the year.
Patients who are most likely to benefitor those that have high prescription
(12:13):
cost early in the year and have difficultypaying for their medication costs all at once.
Patients who receive extra helpor financial assistance
for their medicationsare not eligible for the program.
Once patients enroll,they will pay $0 at the pharmacy
and receive a monthly bill from their plan.
A new BINand PCN that begins and MPPP will be billed
(12:37):
and pharmacies will be reimbursedwithin 14 to 30 days.
All right, folks.
That's all the time we have for today.
Look out for part two of this month's firstFill podcast that will release next Thursday.
I'll talk to a community pharmacistabout what she's
seen on the front lines regarding the M3P.
As we mentioned before,we do have that patient facing resource available
(13:00):
in the billing centeron pharmacist.com about the M3P
and that was created with supportfrom Johnson and Johnson.
Feel free to use itwhen answering questions from your patients.
And last but not least, don'tforget to head over to the learning library
at learn.pharmacist.comto earn your CE for this month's podcast.
CE is available for both pharmaciesand pharmacy technicians this month.
(13:23):
Take care.
Welcome to the First Fill and Happy New Year!
As we move into 2025, this monthwe wanted to be sure to highlight
some new updates to Medicare that are happeningright now due to the Inflation Reduction Act.
If you're serving patients out in the community,you're likely
getting questionsabout the Medicare prescription payment plan.
And we are here to provide you with answers.
(00:25):
I'll also mention that if you visit our billingand payments center on pharmacist.com,
we've created a one page resource with supportfrom Johnson and Johnson for you to use
to help educate your patientsabout the Medicare prescription payment plan.
Definitely check it outand I hope that you find it extremely helpful.
Before we dive in today,I'd like to introduce my guests,
APhA Executive fellow, Nick and APhA
(00:47):
Education Team's newest team member, Maya.
Nick and Maya, why don't you introduce yourselves?
Hey, everyone.
I'm Nick, and as Katie said, I'm the executivefellow here with education this year.
Happy to be here and excited to get started.
Hello. Hello.
My name is Maya Harris.
You may remember meas one of the education fellows last year.
(01:09):
I now serve as Senior Managerof educational activities
here at APhA and I am happy to be back.
All right.
We're glad to have you both.
Thanks so much, Nick and Maya.
Let's dive in.
Before we get into the detailsof the Medicare prescription payment plan,
I wanted to talk through just a few other relevantupdates to Medicare that have occurred recently
(01:30):
due to the Inflation Reduction Act,which was originally signed into law in 2022.
First, Medicare beneficiaries
now have insulin available at $35 per monthper covered prescription.
They also have access to recommendedadult vaccines at zero cost.
New for 2025, the out-of-pocket
(01:51):
prescription drug cost is now capped at $2,000.
Once patients meet that out-of-pocket maximum,
they will no longer incur costsfor their prescription drugs.
In addition to
these benefits, such as lower costsprescription drugs,
Medicare is now able to negotiatedirectly with drug manufacturers
to lower the price of some of the costliestsingle source brand name part B and D drugs,
(02:16):
enabling increased access to innovative
lifesaving treatments at lower costs.
Throughout the past quarter,HHS has announced cost savings
for a total of 118 Part B prescription drugs.
Most recently on December28, 64 drugs were added to the list,
including lifesaving medications for substance use disorder,
(02:37):
large B-cell lymphoma and more.
One other update that's brandnew for 2025 is the Medicare prescription
payment program that's very relevantfor our community pharmacy practitioners
as it has implicationsfor billing as well as questions for patients.
We wanted to dive into more of thisspecifically today to help listeners understand
(02:59):
the benefit and also answer some questionsthat may come your way.
Next week, I'll talk to a community pharmacypractitioner who will share her experience
navigating the Medicare prescriptionpayment plan so far in 2025.
So this brings me to my first question, Maya.
What exactly is the Medicare prescriptionpayment plan
(03:19):
and how can it benefit our patients?
Sure, Katie.
The Medicare prescription payment plan, also known
as M3P, is a programthat allows Medicare beneficiaries
to spread out the cost of their prescription drugsover the course of the year.
Older adults enrolled at Medicare are eligible
(03:39):
if they have a Medicare PartD prescription plan, either standalone
Part D, or coveragethat is part of a Medicare Advantage plan.
And so when thinking about how this works,it's important to remember the additional update
for 2025, which is the $2,000
out-of-pocket maximum for Medicare prescriptiondrug costs.
(04:01):
So in thinking about that, for a patient
who would typically reach their $20 maximumin January all at once
when rolls would no longer pay $2,000 in January,
but $166.67 monthly throughout the year.
So essentially, the plan helps Medicare
beneficiaries spread the cost at their medicationsthroughout the entire year
(04:26):
rather than having high cost earlier in the year.
Thanks, Maya.
When you're talking about it,it kind of reminds me of my gas bill, right?
How I pay a million dollars(exagerrating of course), in the winter
to heat my house and then much less in the summer,
I think my utility companyactually offers a plan similar to this.
Maybe I should look into it.
(04:46):
All right.
Got a little bit off track there for a minute.
Sorry about that.
So, Nick, can you tell listenerswhat patients would benefit
most from therapy if there are any restrictionsfor patient enrollment?
And then what patients can expectafter they enroll and therapy?
Yeah, of course, Katie.
(05:06):
So thinking about how the plan works, the patientswe should be suggesting the plan
to are those that are taking either oneor multiple costly medications and have difficulty
paying for their medication costsall at once or earlier in the year.
Patients that have generally low medication costsreally won't see a benefit
as they likely won't even meet that $2,000out of pocket maximum throughout the year.
(05:29):
As you mentioned before, patientswith the general Medicare Part D plan
or Medicare Part D through a Medicare Advantageplans
are eligible to enrolland it isn't active enrollment.
So they have to go and do it themselves.
Patients who receive extra helpor other financial assistance
for their medicationsdo not qualify for the program.
The program does not reducethe cost of a patient's medications.
(05:51):
It simply spreads them out throughout the year.
For patientswho have trouble paying for their medications
and are looking to reduce their costs,it's prudent
to suggest that they look into the extra helpprogram to see if they qualify.
An area of potential confusionis that enrollment cannot be done in the pharmacy
in order to enrollpatient needs to contact their Medicare plan
(06:12):
to let them know that they would like to enrollafter contacting the Medicare plan.
It typically takes about 24 hoursto process the enrollment.
Once they're enrolled,they will pay a $0 copay at the pharmacy
and receive a separate billfrom their Medicare plan each month.
Again,
after contacting their plan,it takes about 24 hours for them to get set up,
(06:32):
so they may need to waitto pick up their medications
if they're expecting that $0 co-payat the pharmacy after they enroll in the program.
They will also receive a program overviewfrom their plan that includes the effective date
of their participationand examples of their maximum
monthly out-of-pocket costsbased on their current medication regimen.
These costs change based on new prescriptionsthat they receive and other factors
(06:53):
like when they enroll.
Basically,if patients would benefit from the program, it's
best for themto enroll as early in the year as possible.
So the cost is spread out as evenly as possible.
Awesome. Thanks, Nick.
So, Maya, let's shift gears a little bit
to the pharmaciesresponsibilities related to that program.
Can you tell listeners a little bitabout what pharmacies should be doing?
(07:15):
Ofcourse Katie,
one important detailthat was written into the Inflation Reduction
Act is in the section titled Targeted Part
D Enrollee Notification at Point of Sale.
And in this section, the CMS states
that Part D sponsors and pharmacies must use
(07:35):
a $600 single prescription POS threshold
to identify enrolleeslikely to benefit from the M3P.
Now, this approach helps to identify individuals
with a very highlikelihood of benefiting from M3P.
When this occurs,the pharmacies should provide the patient
(07:55):
with the Medicare prescription payment planlikely to benefit notice
either in paper format or via phonethat they may benefit from the program.
So a few key points to communicatewith your patients.
They must enroll directlythrough their Medicare plan
and cannot enroll at the pharmacyonce their plan is active.
(08:17):
They'll be able to pay $0 for their prescriptions
at the pharmacyand receive a monthly bill from their plan.
If they have questions about what their monthly
payment will be based onthe current list of medications.
They should contact their plan.
You might
also be wondering howbilling and reimbursement works.
(08:37):
So once the patients are enrolledafter waiting 24 hours for the plan to be active,
the pharmacy will begin to use the PIN or PCN
that begins with MPPP.
If you submit a claim to their current plan,you'll receive the M3P bin
and PCN from the plan electronically.
(08:58):
After submitting a claim using the MPPP
and PCN you will receive a paid response
reflecting the prescription drug plan and patient
responsibility amounts for electronic claims.
You will receive reimbursement from Medicare planswithin 14 days.
Now, the reimbursement will take 30 days
(09:19):
for any claimsthat are not submitted electronically.
This is a very important pointthat I want to enforce.
We actually ran a survey latelast year and pharmacies
were concerned about reimbursement with the M3P.
Now, rest assured,you will be reimbursed by the plan
either electronically within 14 daysor within 30 days for other claims.
(09:45):
Great.
Thanks so much for that, Maya.
Before we wrap up today, Nick,in talking through this,
we thought of a few questions that we felt thatpharmacies and pharmacy technicians might get.
Can you review those and the answersto the questions with our listeners?
Yes, sure, Katie.
First, patients are likely to ask abouthow much their costs will be.
(10:06):
And while they'll pay $0 at the pharmacy,their monthly cost
will vary depending on their currentand future medication list when they enroll, etc..
Your best bet as a pharmacist or pharmacytechnician is to refer them to their plan.
For more information about whattheir monthly bill is going to look like,
you can reinforce a new out-of-pocketmaximum of $2,000
(10:26):
so that they will payno more than that amount in 2025.
Patients may
also ask if it matters what pharmacy they go toif they enroll.
The costs for their prescriptions
are probably going to vary on whethertheir selected pharmacy is in or out of network
or if they're using a mailer serviceor another type of pharmacy,
just as they would if they were not using the M3P.
(10:47):
Patients can contact their Medicare planto see if they need
help decidingwhich pharmacy to use for the lowest cost.
As a reminder, though, once enrolled in the plan,
they will pay nothing at the pharmacyand be billed by their plan monthly.
If patients askedwhat happens if they miss a monthly payment,
the answer should be deferred to their planwill then inform them of next steps.
(11:08):
if a payment is missed.
And lastly, if patients are lookingfor additional resources or other information,
they can visit their Medicare plan's websiteor call them for more information.
If they need help contacting their plan,they should call 1-800-MEDICARE.
So M-E-D-I-C-A-R-E.
You can also provide themwith the one pager that we created that's
(11:29):
available on the billing center on pharmacist.com.
It does a really nice jobof breaking everything down
and answeringsome of these frequently asked questions.
Awesome.
Thanks so much Nick and Maya for joining me todayand providing these important
updates about Medicare for pharmacy professionals.
So just to summarize, major takeaways in 2025,the maximum
(11:50):
out-of-pocket prescription drug costs for patientsenrolled in
Medicare is now $2,000.
The medication prescription payment planor M3P, is a new option
to help patients with budgeting which helps themto spread their costs across the full year
instead of paying higher amountsin the beginning of the year.
Patients who are most likely to benefitor those that have high prescription
(12:13):
cost early in the year and have difficultypaying for their medication costs all at once.
Patients who receive extra helpor financial assistance
for their medicationsare not eligible for the program.
Once patients enroll,they will pay $0 at the pharmacy
and receive a monthly bill from their plan.
A new BINand PCN that begins and MPPP will be billed
(12:37):
and pharmacies will be reimbursedwithin 14 to 30 days.
All right, folks.
That's all the time we have for today.
Look out for part two of this month's firstFill podcast that will release next Thursday.
I'll talk to a community pharmacistabout what she's
seen on the front lines regarding the M3P.
As we mentioned before,we do have that patient facing resource available
(13:00):
in the billing centeron pharmacist.com about the M3P
and that was created with supportfrom Johnson and Johnson.
Feel free to use itwhen answering questions from your patients.
And last but not least, don'tforget to head over to the learning library
at learn.pharmacist.comto earn your CE for this month's podcast.
CE is available for both pharmaciesand pharmacy technicians this month.
(13:23):
Take care.
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