Prescription Drug Assistance Programs
Guidance for coordination between CMS, State programs, insurers, employers, and all other payers of prescription drug benefits to ensure that the prescription drug benefits provided to Medicare beneficiaries enrolled in Medicare Part D are maximized and the integrity of the Medicare program is assured. CMS has implemented data exchanges with Prescription Drug Assistance Programs including State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs (ADAPs), and Patient Assistance Programs (PAPs) to coordinate Medicare Part D prescription drug benefits with other coverage a Medicare beneficiary may have.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 28, 2019
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and subsequent regulations require coordination between CMS, State programs, insurers, employers, and all other payers of prescription drug benefits to ensure that the prescription drug benefits provided to Medicare beneficiaries enrolled in Medicare Part D are maximized and the integrity of the Medicare program is assured. CMS has implemented data exchanges with Prescription Drug Assistance Programs including State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs (ADAPs), and Patient Assistance Programs (PAPs) to coordinate Medicare Part D prescription drug benefits with other coverage a Medicare beneficiary may have. This allows CMS to facilitate accurate claims payment and the calculation of the Medicare Part D True Out of Pocket (TrOOP) expenses incurred by Medicare beneficiaries.
Medicare Secondary Payer (MSP) rules related to the Part D benefit can be found in § 1860D-2(a) (4) of the MMA. Refer to the Related Links section near the bottom of the page for a link where additional information regarding Prescription Drug Coverage may be found.
Prescription Drug Assistance Programs Part D Data Exchange
CMS exchanges data files with SPAPs, ADAPs, and PAPs to obtain prescription drug coverage information Medicare beneficiaries have under these programs and to provide Medicare Part D coverage information in return. Detailed information on how to establish a Data Sharing Agreement (DSA) and implement a data exchange with CMS for this purpose can be found on the Coordinating Prescription Drug Benefits page of this section. An overview of Part D data exchanges and the coordination of prescription drug benefits can be found in the Downloads section below.
HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.