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Coordinating Prescription Drug Benefits

CMS exchanges data files with State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs (ADAPs), and Patient Assistance Programs (PAPs) to obtain prescription drug coverage information Medicare beneficiaries have under these programs and to provide Medicare Part D coverage information in return. These data exchanges facilitate coordination of a Medicare beneficiary’s prescription drug benefits by:

  • Determining the correct primary payer - Making sure that pharmacy claims are routed to and paid by each insurer or payer in the proper order.
  • Calculating the TrOOP - Information collected is used by CMS to calculate a Medicare beneficiary’s True Out of Pocket (TrOOP) expense to ensure Part D benefits are administered correctly.
  • Notifying Part D Plans - Data collected is provided to Medicare Part D (PD) Plans to assist with their coordination of prescription drug benefits for Medicare beneficiaries they cover.
  • Providing Medicare eligibility information - Part D coverage and Low Income Subsidy eligibility information for covered Medicare beneficiaries is provided to participating Prescription Drug Assistance Programs.

To Establish Your Part D Data Exchange as a:

State Pharmaceutical Assistance Programs (SPAP) / AIDS Drug Assistance Program (ADAP):

  • Use the Health Plan Management System (HPMS) to enter into a Data Sharing Agreement (DSA). To access HPMS, please use the following link for guidance: Health Plan Management System (HPMS)
  • Complete the DSA within HPMS and submit for approval.
  • Upon receiving approval, you will be contacted by the Benefits Coordination & Recovery Contractor for technical direction to set up your file transmission method, testing and implementation.
  • For additional information and guidance for exchanging Part D data, please access the applicable ADAP and SPAP User Guides posted in the Downloads section below.

Patient Assistance Programs (PAP):

  • Review the PAP DSA and questionnaire posted in the Downloads section below.
  • Complete the DSA and questionnaire and submit to CMS per the instructions in the PAP User Guide.
  • Once all approvals have been obtained, you will be contacted by the Benefits Coordination and Recovery Contractor for technical direction to set up your file transmission method, testing and implementation.
  • For additional information and guidance, please review the PAP User Guide posted in the Downloads section below.

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