YOUR 2026 PHARMACY GUIDE

The role of pharmacists has never been more critical. As the most accessible healthcare professionals, you stand on the front lines, helping patients navigate the labyrinth of insurance, cost, and access to their medications. The Medicare Prescription Payment Plan is the resource to help your patients.

In an environment where high prescription drug costs force many seniors to choose between their medications and other necessities — a choice that often feels impossible — programs designed to alleviate this burden are essential. That’s why the Centers for Medicare & Medicaid Services (CMS) created the Medicare Prescription Payment Plan (M3P). This program transforms patient access by offering Medicare beneficiaries the option to pay nothing upfront for their Part D prescriptions at the pharmacy counter, and then spread those costs over the plan year, with no interest or fees.

Here is free access to the M3P Webinar:

For Pharmacists

For Pharmacy Technicians

Q & A from M3P Webinar

While the initial response to the M3P was positive, the rollout presented new complexities at the pharmacy counter. Despite some preliminary hurdles, as we look ahead to 2026, our focus is on clarity. The goal is to ensure a smooth, predictable, and positive experience for both your staff and your patients.

This comprehensive guide is designed to give you and your team the knowledge and tools to master the M3P and minimize administrative headaches to provide your patients with a new tool to increase adherence.

Key M3P knowledge for pharmacy staff

For successful implementation of the Medicare Prescription Payment Plan at your pharmacy, your team should be prepared to handle the process flow, billing changes, and patient communications with confidence. Understanding the mechanics of the program is the first step toward a seamless experience in 2026.

1. Determining eligibility

It is crucial for your team to quickly verify beneficiary eligibility and understand how the plan works:

Who is eligible? Nearly every Medicare Part D beneficiary (including those with Medicare Advantage plans along with standalone Part D plans) can opt in to the M3P at any time. This program is voluntary, and beneficiaries who want to participate must opt in.

Who benefits? While anyone can enroll, the program is best for those who will incur significant out-of-pocket costs (especially early in the year), and those whose costs approach the $2,100 annual maximum out of pocket.

What drugs are covered? Only medications covered under Part D are eligible, so additional vitamins or supplements may still require patient co-pays. However, medications covered by an exception are also eligible for the M3P.

2. Decoding new status codes

The primary communication between the plan and the pharmacy is through claim status codes. Your team should be able to recognize the new codes associated with the M3P to ensure accurate processing and billing.

The pharmacy has a mandated responsibility to notify the patient if they are “Likely to Benefit” when:

A patient presents an eligible prescription.
The out-of-pocket cost for a single covered Part D drug exceeds $600.

When a Part D claim returns a specific message code, it indicates the M3P status:

 Handling the claim cycle

The M3P introduces a two-step claim process, where the pharmacy must submit both a primary claim (to the PBM for coverage) and a secondary claim (to the M3P system for payment distribution).

1. Primary claim processing (PBM responsibility)

Step 1: Status notification: The primary claim submitted to the PBM will return one of the message codes above (e.g., 056, 057, 058), indicating the beneficiary’s M3P enrollment status.
Step 2: Collect/dispense: If the code is 057 (Enrolled), proceed to readjudicate the claim under the secondary BIN and PCN. If the code is 056 (Likely to Benefit), the PBM mandates the pharmacy provide the patient with the “Learn More” CMS-10882 notice and collect the full co-pay if the patient wants to fill the drug immediately without enrolling in the program.

2. Secondary claim submission (M3P system)

This step is required only if the primary claim returns 057 (Enrolled).
The secondary claim is submitted using the NCOP (No Cost Out-of-Pocket) field requirements. The primary purpose is to inform the M3P system (which is administered by the PBMs) of the total claim cost and the patient liability amount ($0), so the M3P system can calculate and initiate the monthly payment plan.
The pharmacy receives the M3P amount from the plan, and the patient pays $0 at the point of sale.

3. Payment rules and installment calculation

The pharmacy’s responsibility is to submit the claim accurately and receive payment promptly. The pharmacy is NOT responsible for calculating the monthly installment payments.

Installment calculation (The plan’s role): The plan (or PBM) calculates the monthly installment based on the remaining balance of the patient’s actual incurred out-of-pocket costs, or the maximum remaining OOP, whichever is less. This figure is then spread equally across the remaining months in the plan year.

Prompt payment rule: The Part D plan must reimburse the pharmacy according to standard Part D prompt payment rules for the M3P portion of the claim.

NO risk for the pharmacy: If the patient fails to pay their monthly installment to the plan, that risk of non-payment is absorbed by the Part D Plan, not the pharmacy.

GetMyMeds.com: Improving the beneficiary experience at the pharmacy counter

In 2025, it was clear that beneficiaries had trouble understanding the M3P program and opting in. As a result, this caused more friction at the pharmacy counter causing long lines, patient confusion, and fewer opt-ins by those who would have benefited from the program. While the fastest way to opt in is by calling the plan, phone trees can be confusing and frustrating for beneficiaries, who may not know how to request to opt in to the M3P, potentially leading to prescription abandonment and lower adherence.

As a simple solution for pharmacists and pharmacy technicians, GetMyMeds.com is a comprehensive website that explains the M3P program and helps beneficiaries opt in. The site contains a secure opt-in tool that allows beneficiaries to find their plan’s form and fill it out – then, GetMyMeds securely transmits it to their plan for free. If a beneficiary is Likely To Benefit, it’s recommended to share the link or suggest M3P as far in advance as possible of the beneficiary’s trip to the pharmacy to allow plenty of time for them to opt in so that they appear 057 at the counter.

Patient Link

Disclaimer: GetMyMeds.com is not affiliated with the Centers for Medicare & Medicaid Services. Visit GetMyMeds.com for program details.