Medicare Beneficiaries May Not Find Out Drug Costs Until They Get a Bill In the Mail…A Month Later

🚫Use extreme caution with Medicare beneficiaries opting into the M3P. Unless they are well advised on their prescription costs prior to picking them up at the pharmacy, they could end up blind to their cost until they get their monthly M3P Bill.🚫

❌ Pharmacies are NOT required to provide financial information to beneficiaries in the M3P, and they won’t know their OOP cost share that is being added to their M3P balance. They may chose to advise beneficiaries of a Rx retail cost, if the cost is high or it is a new Rx, but it is NOT required. ❌

This is, by far, the most unsettling aspect of the program, in my opinion.

I can’t even imagine the CTMs that this could generate.

Great agents/brokers are going to be the bridge in this massive gap. 💜

Full story:

For the past several months, I have felt a bit like “Chicken Little” as I have excitedly rattled off all of my concerns about the pitfalls of the M3P to anyone who would listen and was often met with an unruffled response. A select few shared my concerns and have been wonderful sounding boards. I’m looking at you David Kline. Thank you for being awesome and leading the carrier charge.

A massive thank you to voices like William Sarraille, Deborah Williams and Jennifer Snow for being such vocal, expert leaders in this space. I am grateful for you.

Last week, when discussing the M3P claims billing process similarity with LIS, and how it alters the OOP responsibility at the POS, I was struck with a sense of impending dread that beneficiaries enrolled in the M3P may not be aware of their OOP cost share responsibility for their prescriptions until upwards of a month after taking them home.

I went through the Part 1 Final Guidance again, and reread a comment/response that had given me pause during my intital read-through, but I hadn’t fully understood its magnitude. I’ve included a screenshot of the comment/response below. The final words of the response were:

“There is no statutory requirement for pharmacies to provide financial information to Part D Enrollees.”

I went back and reread the IRA Section 11202, no mention. So, I went back to the Part 1 Guidance and read the claims billing process again.

The pharmacy representative will see $0 for the beneficiary responsilbity. They will not have details on the beneficiaries final OOP cost share responsibility while the beneficiary is at the POS. The pharmacy representative may choose to advise the beneficiary of the retail cost of the prescription, but it is not a requirement.

Today I attended the first CMS National Pharmacy IRA Educational Outreach webinar and what I had suspected was confirmed.

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