Impacted: Medicare clients

What you need to know 
As part of our continued commitment to keep clients informed on the monitoring of critical capabilities of the Medicare Prescription Payment Plan (M3P) that went live Jan. 1, 2025, Prime Therapeutics (Prime) would like to share more information on an enhanced daily monitoring program, effective Feb. 24, 2025. 

Overview 
As you may be aware, Medicare members now have the ability to opt in to CMS’ Medicare Prescription Payment Plan (M3P), which provides members the option to pay out-of-pocket drug costs via monthly payments throughout the year. 

Much like Coordination of Benefits (COB), these Medicare Part D claims contain a primary and secondary claim. The primary claim is billed to Medicare Part D, and the secondary claim is billed to the M3P plan. M3P claim processing is incumbent upon the pharmacy to complete. While some pharmacies may have automated processes to submit these claims to the M3P plan, others may not. Manual processes may not always be completed immediately, and there may be a lag between the Medicare Part D claim processing and M3P claim processing. 

Note: CMS has not outlined a turnaround time requirement for pharmacies to submit M3P claims for processing. 

How Prime will support timely claims processing 
To ensure claims and eligible elections process correctly and in a timely manner, Prime closely monitored claims during peak season. Based upon client feedback, we have now taken steps to formalize an enhanced daily monitoring program. 

Beginning Feb. 24, 2025, Prime will launch an enhanced pharmacy outreach effort based on a lag of M3P eligible primary claims without a submitted secondary M3P claim.  

Criteria for outreach associated with monitoring these claims include: 

• Prime will review a daily report that contains primary claims submitted with no identified secondary M3P claim within 48 hours. 
• Prime’s Provider Relations team will then initiate outreach to pharmacies where a processed secondary M3P claim does not exist within 72 hours after the initial claim was submitted. Depending on the volume, this outreach may take more than one business day. 
• Prime will prioritize older claims first and move to newer identified claims. 

Separately, Prime will distribute reports of all M3P eligible primary claims without a subsequent M3P claim to clients. There will not be any filtered time lag associated with this report. Clients can utilize these reports for their own review but should note provider relations will only take action at the 72-hour mark and beyond. 

Note: Rejected claims will not be included at this time. 

For additional resources, please visit the Inflation Reduction Act - M3P page on our website.

We appreciate your collaboration and are committed to offering proactive support to meet your needs and those of your members. 

Questions?
Please direct any questions to your account team representative.