Title 42 — The Public Health and WelfareRelease 119-73

§1395w–134 Coordination requirements for plans providing prescription drug coverage

Title 42 › Chapter CHAPTER 7— - SOCIAL SECURITY › Subchapter SUBCHAPTER XVIII— - HEALTH INSURANCE FOR AGED AND DISABLED › Part Part D— - Voluntary Prescription Drug Benefit Program › Subpart subpart 3— - application to medicare advantage program and treatment of employer-sponsored programs and other prescription drug plans › § 1395w–134

Last updated Apr 6, 2026|Official source

Summary

The Health Secretary must apply the same benefit-coordination rules used for State Pharmaceutical Assistance Programs to other prescription drug plans. The Secretary can also set rules for how plans send and share the information needed to coordinate benefits. The Secretary may charge fees to cover the cost of sending that information and may keep part of those fees, but cannot charge those fees to State Pharmaceutical Assistance Programs. The kinds of plans covered include certain Medicaid state plans, employer group health plans, the Federal Employees Health Benefits Plan, military health coverage, and other plans the Secretary names that help people who qualify for Medicare Part D buy prescription drugs. These rules do not stop Medicare drug plans or Medicare Advantage plans from using cost-control tools (like paying different amounts for different drugs), and they do not change other existing procedures for sharing information.

Full Legal Text

Title 42, §1395w–134

The Public Health and Welfare — Source: USLM XML via OLRC

(a)(1)The Secretary shall apply the coordination requirements established under section 1395w–133(a) of this title to Rx plans described in subsection (b) in the same manner as such requirements apply to a State Pharmaceutical Assistance Program.

(2)To the extent specified by the Secretary, the requirements referred to in paragraph (1) shall apply to procedures established under section 1395w–102(b)(4)(D) of this title.

(3)(A)The Secretary may impose user fees for the transmittal of information necessary for benefit coordination under section 1395w–102(b)(4)(D) of this title in a manner similar to the manner in which user fees are imposed under section 1395u(h)(3)(B) of this title, except that the Secretary may retain a portion of such fees to defray the Secretary’s costs in carrying out procedures under section 1395w–102(b)(4)(D) of this title.

(B)A user fee may not be imposed under subparagraph (A) with respect to a State Pharmaceutical Assistance Program.

(b)An Rx plan described in this subsection is any of the following:

(1)A State plan under subchapter XIX, including such a plan operating under a waiver under section 1315 of this title, if it meets the requirements of section 1395w–133(b)(2) of this title.

(2)An employer group health plan.

(3)The Federal employees health benefits plan under chapter 89 of title 5.

(4)Coverage under chapter 55 of title 10.

(5)Such other health benefit plans or programs that provide coverage or financial assistance for the purchase or provision of prescription drug coverage on behalf of part D eligible individuals as the Secretary may specify.

(c)(1)The requirements of this section shall not impair or prevent a PDP sponsor or MA organization from applying cost management tools (including differential payments) under all methods of operation.

(2)The requirements of this section shall not affect the application of the procedures established under section 1395w–102(b)(4)(D) of this title.

Reference

Citations & Metadata

Citation

42 U.S.C. § 1395w–134

Title 42 — The Public Health and Welfare

Last Updated

Apr 6, 2026

Release point: 119-73