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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:

  • Review the Data Sharing Agreement (DSA) and User Guide materials pertinent to your program posted in the Downloads section below.
  • Contact CMS to initiate your DSA and submit the Implementation Questionnaire that applies to your program.  All Implementation Questionnaires are found in the Downloads section below.
  • Complete and sign your DSA with CMS.
  • Set up your file transmission method and develop software according to requirements in the applicable User Guide below.
  • Test and implement the file exchanges with CMS.
  • Maintain your data exchange according to User Guide updates posted to this page.