Medicare Prescription Payment Plan (M3P)
The Medicare Prescription Payment Plan (sometimes referred to as the M3P or MPPP) is a new payment option that will be available to anyone with a Medicare Advantage plan with drug coverage. Beginning on October 15, 2024, you may sign up for the Medicare Prescription Payment Plan, which will be effective January 1, 2025. The Medicare Prescription Payment Plan will allow you to manage your out-of-pocket Medicare Part D drug costs (prescription drug costs) by spreading them across the calendar year (January-December). If you select this payment option, you will continue to pay your premium (if you have one), and you’ll get a bill from OptumRx each month to pay for your prescription drugs (instead of paying at the pharmacy).
Quartz Medicare Advantage (HMO) and Quartz Dual Eligible have partnered with OptumRx for this prescription payment program. OptumRx is a pharmacy benefit manager that works with Quartz to administer pharmacy benefits.
Overview
- There is no cost to participate in the Medicare Prescription Payment Plan.
- You won’t pay any interest or fees on the amount you owe, even if your payment is late.
- Pay nothing at the pharmacy counter. After you enroll in the Medicare Prescription Payment Plan, you can pick up your prescriptions at the pharmacy and owe $0 to the pharmacy. You will instead be responsible for paying a monthly bill for the prescriptions you fill.
- Spread your cost over the rest of the plan year. Pay for your prescriptions in monthly installments over the remaining months of the year after you enroll.
- Your prescription costs are capped after you reach your yearly $2,000 out-of-pocket maximum.
- Once you reach the out-of-pocket maximum for the plan year, additional prescription drug costs will not be added to your Medicare Prescription Payment Plan program balance.
- You will continue to pay your monthly billed amount for the rest of the plan year, or you can pay the balance in a lump sum.
- You can end your participation in the Medicare Prescription Payment Plan anytime. However, you will be responsible to pay your Medicare Prescription Payment Plan balance owed in monthly payments or in a lump sum payment even if you stop participating in the program.
- If you stop participation in the Medicare Prescription Payment Plan, you will return to paying for your prescriptions at the pharmacy.
- Call OptumRx Customer Service at (800) 506-4614 to enroll or for additional information or questions related to the Medicare Prescription Payment Plan.
How does it work?
After you enroll in the Medicare Prescription Payment Plan, when you fill a prescription for a drug covered by Part D you won’t pay at the pharmacy (including mail order and specialty pharmacies). Instead, you’ll get a bill each month from OptumRx.
Even though you won’t pay for your drugs at the pharmacy, you’re still responsible for the costs. This payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. Whether you participate in the Medicare Prescription Payment Plan or not, you will never pay more than $2,000 in a plan year for your covered Part D medications.
Will the Medicare Prescription Payment Plan help me?
It depends on your situation. Remember, this payment option might help you manage your monthly expenses, but it doesn’t save you money or lower your drug costs. You are most likely to benefit from participating in the Medicare Prescription Payment Plan if you have high drug costs earlier in the calendar year. Although you can start participating in this payment option at any time in the year, starting earlier in the year, gives you more months to spread out your drug costs. See the three examples below for more information and sample monthly payment calculations.
This payment option may not be the best choice for you if:
- Your yearly drug costs are low.
- Your drug costs are the same each month.
- You sign up for the Medicare Prescription Payment Plan late in the calendar year (after September).
- You get or are eligible for Extra Help from Medicare or a Medicare Savings Program.
- You get help paying for your drugs from other organizations, like a State Pharmaceutical Assistance Program (SPAP), a coupon program, or other health coverage.
- Visit Medicare.gov – Will this help me to learn more about how this payment option can help you.
- Visit Medicare.gov – Prescription Payment plan to learn more.
Who can help me decide if I should participate?
- You can call OptumRx Customer Service at (800) 506-4614 for answers to your questions.
- Medicare: Visit Medicare.gov – Prescription law to learn more about this payment option and if it might be a good fit for you.
- State Health Insurance Assistance Program (SHIP): Visit SHIP Help to get the phone number for your local SHIP and get free, personalized health insurance counseling.
You can also visit OptumRx to learn more and sign up for the Medicare Prescription Payment Plan. This link opens an OptumRx website in a new browser window.
Where can I get more information?
- Call OptumRx Customer Service (800) 506-4614 for additional information or questions related to the Medicare Prescription Payment Plan.
- Medicare: Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
What to know if I’m participating
What happens after I sign up?
OptumRx will review your participation request. After review, OptumRx will call you on behalf of Quartz and send you a letter confirming your participation in the Medicare Prescription Payment Plan. You will not receive a call if you are on the Do Not Call list.
Then:
- When you get a prescription for a drug covered by your Quartz Medicare Advantage prescription coverage, you won’t pay the pharmacy for the prescription. However, you’re still responsible for the costs. If you want to know what your drug will cost before you take it home, call OptumRx Customer Service (800) 506-4614 or ask your pharmacist.
- Each month, OptumRx will send you a bill for your prescriptions and information on how to make a payment. You’ll get a separate bill for your monthly plan premium (if you have one).
- You may also pay your bill in the QuartzRx Member Portal.
What happens if I don’t pay my bill?
You’ll get a reminder from OptumRx if you miss a payment. If you don’t pay your bill by the date noted in that notice, you’ll be removed from the Medicare Prescription Payment Plan. You’re required to pay the amount you owe, but you won’t pay any interest or fees, even if your payment is late. You can choose to pay that amount all at once or be billed monthly. Call OptumRx Customer Service (800) 506-4614 if you think there is a mistake on your Medicare Prescription Payment Plan bill.
Always pay your Quartz Medicare Advantage or Dual Eligible plan monthly premium first (if you have one), so you don’t lose your drug coverage. If you’re concerned about paying both your monthly plan premium and Medicare Prescription Payment Plan bills, go to the section below titled “What programs can help lower my costs?” to learn about programs that can help lower your costs.
How is my monthly bill calculated?
When you are billed monthly, the bill will be based on what you would have paid for any prescriptions you get, plus your previous month’s balance, divided by the number of months left in the year. All plans calculate the monthly payments in the same way. See the three examples below for more information and sample monthly payment calculations.
Your payments may change every month, so you might not know what your exact bill will be ahead of time.
Future payments may increase as you fill prescriptions because as new out-of-pocket costs get added to your monthly payment, there are fewer months left in the year to spread out your remaining payments.
In a single calendar year, you’ll never pay more than:
- The total amount you would have paid out of pocket to the pharmacy if you weren’t participating in the Medicare Prescription Payment Plan.
- The Medicare drug coverage annual out-of-pocket maximum ($2,000).
You will never pay more than $2,000 in 2025 for Part D covered prescription drugs. This applies to everyone with Medicare drug coverage, even if you don’t participate in the Medicare Prescription Payment Plan.
You can leave the Medicare Prescription Payment Plan at any time by calling OptumRx Customer Service at (800) 506-4614. Leaving won’t affect your Medicare drug coverage or other Medicare benefits. Keep in mind:
- If you still owe a balance you’re required to pay the amount you owe, even though you’re no longer participating in this payment option.
- You can choose to pay your balance all at once or be billed monthly.
You’ll pay the pharmacy directly for new out-of-pocket drug costs after you leave the Medicare Prescription Payment Plan.
What programs can help lower my costs?
If you have limited income and resources, you may be eligible for one of these programs:
- Extra Help: A Medicare program that helps pay your Medicare drug costs. Provides assistance in affording Medicare prescription drug coverage premiums and out-of-pocket drug costs to certain individuals with limited resources and who earn up to 150% of the federal poverty level. Visit Medicare.gov – Extra help to find out if you qualify and apply. You can also apply with your State Medical Assistance (Medicaid) office. Visit Medicare.gov – Help with drug costs to learn more.
- Medicare Savings Programs: State-run programs that might help pay some or all of your Medicare premiums, deductibles, copayments, and coinsurance. Visit Medicare.gov – Savings programs to learn more.
- State Pharmaceutical Assistance Programs (SPAPs): Programs that might include coverage for your Medicare drug plan premiums and/or cost sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Visit Medicare.gov – SPAP help to learn more.
- Manufacturer Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs [PAPs]): Programs from drug manufacturers to help lower drugs costs for people with Medicare. Visit Medicare.gov – PAP help to learn more.
- The Inflation Reduction Act of 2022. This new law provides more assistance in affording Medicare prescription drug coverage premiums and out-of-pocket drug costs by expanding the low-income subsidy program (LIS or “Extra Help”) under Medicare Part D to 150% of the federal poverty level starting in 2024. From: CMS.gov – Inflation Reduction Fact Sheet
- Expanded Eligibility for Extra Help: CMS finalized regulations to expand eligibility for the full low-income subsidy (LIS) benefit (also known as “Extra Help”) to certain individuals with limited resources and who earn up to 150% of the federal poverty level. Beginning January 1, 2024, this change will provide the full subsidy to those who currently qualify for the partial subsidy. This action will improve access to affordable prescription drug coverage for approximately 300,000 individuals with Medicare. From: CMS.gov – Part-D Fact Sheet
Many people qualify for savings and don’t realize it. Visit Medicare.gov – Get help with costs or contact your local Social Security office to learn more. Find your local Social Security office at SSA.gov – Office locator.
Medicare Prescription Payment Plan complaints and grievances You have the right to file a complaint or grievance regarding the Medicare Prescription Payment Program. Please contact us by telephone at (800) 394-5566 (TTY:711). We are available to assist you, Monday through Friday from 8 a.m. to 8 p.m. In addition, from October 1 through March 31 we are available Saturday and Sunday from 8 a.m. to 8 p.m. For more information about complaints and grievances, please review your Evidence of Coverage (EOC) document. You can view your EOC by logging in to your Quartz MyChart.
Examples of how a monthly bill is calculated
Example 1 - You take several high-cost drugs that have a total out-of-pocket cost of $500 each month.
You take several high-cost drugs that have a total out-of-pocket cost of $500 each month. In January 2025, you join the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
First, we figure out your “maximum possible payment” for the first month:
2,000 [annual out-of-pocket maximum]
– $0 [no out-of-pocket costs before using this payment option]
= $2,000
/12 [remaining months in the year]
= $166.67 [your “maximum possible payment” for the first month]
Then, we figure out what you’ll pay for January:
- Compare your total out-of-pocket costs for January ($500) to the “maximum possible payment” we just calculated: $166.67.
- Your plan will bill you the lesser of the two amounts. So, you’ll pay $166.67 for the month of January.
- You have a remaining balance of $333.33 ($500-$166.67).
For February and the rest of the months left in the year, we calculate your payment differently:
$333.33 [remaining balance] + $500 [new costs]
= $833.33
/11 [remaining months in the year]
= $75.76 [your payment for February]
We’ll calculate your March payment like we did for February:
$757.57 [remaining balance] + $500 [new costs]
= $1,257.57
/10 [remaining months in the year]
= $125.76 [your payment for March]
In April, when you refill your prescriptions again, you’ll reach the annual out-of- pocket maximum for the year ($2,000 in 2025).
You’ll continue to pay what you already owe and get your prescription(s), but after April you won’t add any new out- of-pocket costs for the rest of the year.
$1,131.81 [remaining balance] + $500 [new costs]
= $1631.81
/9 [remaining months in the year]
= $181.31 [your payment for April and all remaining months in the year]
Even though your payment varies each month, by the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-pocket
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 1: Start participating in January with high drug costs early in the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $500 | $166.67 | This is when you started participating in this payment option. Your first month’s bill is based on the “maximum possible payment” calculation. |
| February | $500 | $75.76 | |
| March | $500 | $125.76 | |
| April | $500 | $181.31 | This month you reached the annual out-of-pocket maximum ($2,000 in 2025). |
| May | $0.00 | $181.31 * | You’ll still get your $500 drugs each month, but because you’ve reached the annual out-of-pocket maximum, you won’t add new out-of-pocket costs. |
| June | $0.00 | $181.31 * | |
| July | $0.00 | $181.31 * | |
| August | $0.00 | $181.31 * | |
| September | $0.00 | $181.31 * | |
| October | $0.00 | $181.31 * | |
| November | $0.00 | $181.31 * | |
| December | $0.00 | $181.31 * | |
| Total | $2,000.00 | $2,000.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
If you’re concerned about paying $500 each month from January to April, this payment option will help you manage your costs. If you prefer to pay $500 each month for 4 months and then pay $0 for the rest of the year, this payment option might not be right for you. Contact your health or drug plan for personalized help.
Example 2 - You take several drugs that have a total out-of-pocket cost of $80 each month.
You take several drugs that have a total out-of-pocket cost of $80 each month. In January 2025, you join the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
First, we figure out your “maximum possible payment” for the first month:
2,000 [annual out-of-pocket maximum]
– $0 [no out-of-pocket costs before using this payment option]
= $2,000
/12 [remaining months in the year]
= $166.67 [your “maximum possible payment” for the first month]
Then, we figure out what you’ll pay for January:
- Compare your total out-of-pocket costs for January ($80) to the “maximum possible payment” we just calculated: $166.67.
- Your plan will bill you the lesser of the two amounts. So, you’ll pay $80 for the month of January.
- You have a remaining balance of $0.
For February and the rest of the months left in the year, we calculate your payment differently:
$0 [remaining balance] + $80 [new costs]
= $80
/11 [remaining months in the year]
= $7.27 [your payment for February]
We’ll calculate your March payment like we did for February:
$72.73 [remaining balance] + $80 [new costs]
= $152.73
/10 [remaining months in the year]
= $15.27 [your payment for March]
Even though your payment varies each month, by the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-pocket
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 2: Start participating in January with consistent costs throughout the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $80.00 | $80.00 | This is when you started using this payment option. Your first month’s bill is based on the “maximum possible payment” calculation. |
| February | $80.00 | $7.27 | |
| March | $80.00 | $15.27 | |
| April | $80.00 | $24.16 | |
| May | $80.00 | $34.16 | |
| June | $80.00 | $45.59 | |
| July | $80.00 | $58.93 | |
| August | $80.00 | $74.92 | |
| September | $80.00 | $94.93 | |
| October | $80.00 | $121.59 | |
| November | $80.00 | $161.59 | |
| December | $80.00 | $241.59 | |
| Total | $960.00 | $960.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
Depending on your specific circumstances, you might not benefit from using this payment option due to the higher payments that start in September. Contact your health or drug plan for personalized help.
Example 3 - You pay $4 every month in out-of-pocket costs for a prescription you use regularly
You pay $4 every month in out-of-pocket costs for a prescription you use regularly. In April 2025, you need a new one-time prescription that costs $613, so your total out-of-pocket costs in April are $617. That same month, before you fill your prescriptions, you decide to participate in the Medicare Prescription Payment Plan through your Medicare drug plan or Medicare health plan with drug coverage.
We calculate your first month’s bill in the Medicare Prescription Payment Plan differently than your bill for the rest of the months in the year:
First, we figure out your “maximum possible payment” for the first month:
2,000 [annual out-of-pocket maximum]
– $12 [your out-of-pocket costs before using this payment option]
= $1988
/9 [remaining months in the year]
= $220.89 [your “maximum possible payment” for the first month]
Then, we figure out what you’ll pay for April:
- Compare your total out-of-pocket costs for April ($617) to the “maximum possible payment” we just calculated: $220.89.
- Your plan will bill you the lesser of the two So, you’ll pay $220.89 for the month of April.
- You have a remaining balance of $396.11 ($617 – $220.89).
For May and the rest of the months left in the year, we calculate your payment differently:
$396.11 [remaining balance] + $4 [new costs]
= $400.11
/8 [remaining months in the year]
= $50.01 [your payment for May]
Your payments will vary throughout the year. That’s because you’re adding drug costs during the year, but you have fewer months left in the year to spread your payments across.
By the end of the year, you’ll never pay more than:
- The total amount you would have paid out-of-
- The total annual out-of-pocket maximum ($2,000 in 2025).
Remember, this is just your monthly payment for your out-of-pocket drug costs. You still need to pay your health or drug plan’s premium (if you have one) each month.
Example 3: Start participating in April with varying costs throughout the year
| Month | Your drug costs (without this payment option) | Your monthly payment (with this payment option) | Notes |
|---|---|---|---|
| January | $4.00 | $4.00 * | *You made these payments directly to the pharmacy before you started participating in the Medicare Prescription Payment Plan. |
| February | $4.00 | $4.00 * | |
| March | $4.00 | $4.00 * | |
| April | $617.00 | $220.89 | This is when you started using this payment option. Your first month’s bill is based on the “maximum possible payment” calculation. |
| May | $4.00 | $50.01 | |
| June | $4.00 | $50.59 | |
| July | $124.00 | $71.25 | This month, you need a drug that’s $120, in addition to your $4 drug. Your payments increase because you’re adding drug costs during the year, but you have fewer months left in the year to spread your payments across. |
| August | $4.00 | $72.05 | |
| September | $4.00 | $73.05 | |
| October | $124.00 | $114.39 | This month, you need a drug that’s $120, in addition to your $4 drug. Your payments increase because you’re adding drug costs during the year, but you have fewer months left in the year to spread your payments across. |
| November | $4.00 | $116.39 | |
| December | $4.00 | $120.38 | |
| Total | $901.00 | $901.00 | You’ll pay the same total amount for the year, even if you don’t use this payment option. |
If you’re concerned about paying $617 in April, this payment option will help you spread your costs across monthly payments that vary throughout the year. If you’re concerned about higher payments later in the year, this payment option might not be right for you. Contact your health or drug plan for personalized help.
Can I leave the program?