---
kind: "section"
citation: "42 U.S.C. § 1395w–133"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1395w–133"
heading: "State Pharmaceutical Assistance Programs"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1395w-133"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XVIII — Health Insurance for Aged and Disabled"
  - "Part D — Voluntary Prescription Drug Benefit Program"
  - "Subpart 3 — application to medicare advantage program and treatment of employer-sponsored programs and other prescription drug plans"
---

# §1395w–133. State Pharmaceutical Assistance Programs

- (a) **Requirements for benefit coordination—**
  - (1) **In general—** Before July 1, 2005, the [Secretary](/usc/42/1301.md?p=a-6) shall establish consistent with this section requirements for [prescription drug plans](/usc/42/1395w–151.md?p=a-14) to ensure the effective coordination between a part D plan (as defined in [paragraph (5)](#a-5)) and a [State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17) (as defined in [subsection (b)](#b)) with respect to—
    - (A) payment of premiums and coverage; and
    - (B) payment for supplemental prescription [drug](/usc/42/11851.md?p=4) benefits,

    for [part D eligible individuals](/usc/42/1395w–151.md?p=a-4) enrolled under both types of plans.

  - (2) **Coordination elements—** The requirements under [paragraph (1)](#a-1) shall include requirements relating to coordination of each of the following:
    - (A) Enrollment file sharing.
    - (B) The processing of claims, [including](/usc/42/1301.md?p=b) electronic processing.
    - (C) Claims payment.
    - (D) Claims reconciliation reports.
    - (E) Application of the protection against high out-of-pocket expenditures under [section 1395w–102(b)(4) of this title](/usc/42/1395w–102.md?p=b-4).
    - (F) Other administrative processes specified by the [Secretary](/usc/42/1301.md?p=a-6).

    Such requirements shall be consistent with applicable law to safeguard the privacy of any individually identifiable beneficiary information.

  - (3) **Use of lump sum per capita method—** Such requirements shall include a method for the application by a part D plan of specified funding amounts from a [State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17) for enrolled individuals for supplemental prescription [drug](/usc/42/11851.md?p=4) benefits.
  - (4) **Consultation—** In establishing requirements under this subsection, the [Secretary](/usc/42/1301.md?p=a-6) shall consult with [State Pharmaceutical Assistance Programs](/usc/42/1395w–151.md?p=a-17), MA organizations, [States](/usc/42/619.md?p=5), pharmaceutical benefit managers, employers, representatives of [part D eligible individuals](/usc/42/1395w–151.md?p=a-4), the data processing experts, pharmacists, pharmaceutical manufacturers, and other experts.
  - (5) **Part D plan defined—** For purposes of this section and [section 1395w–134 of this title](/usc/42/1395w–134.md), the term “part D plan” means a [prescription drug plan](/usc/42/1395w–151.md?p=a-14) and an [MA–PD plan](/usc/42/1395w–151.md?p=a-9).
- (b) **State Pharmaceutical Assistance Program—** For purposes of this part, the term “[State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17)” means a [State](/usc/42/619.md?p=5) program—
  - (1) which provides financial assistance for the purchase or provision of supplemental prescription [drug](/usc/42/11851.md?p=4) coverage or benefits on behalf of [part D eligible individuals](/usc/42/1395w–151.md?p=a-4);
  - (2) which, in determining eligibility and the amount of assistance to [part D eligible individuals](/usc/42/1395w–151.md?p=a-4) under the Program, provides assistance to such individuals in all part D plans and does not discriminate based upon the part D plan in which the individual is enrolled; and
  - (3) which satisfies the requirements of subsections [(a)](#a) and [(c)](#c).
- (c) **Relation to other provisions—**
  - (1) **Medicare as primary payor—** The requirements of this section shall not change or affect the primary payor status of a part D plan.
  - (2) **Use of a single card—** A card that is issued under [section 1395w–104(b)(2)(A) of this title](/usc/42/1395w–104.md?p=b-2-A) for use under a part D plan may also be used in connection with coverage of benefits provided under a [State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17) and, in such case, may contain an emblem or symbol indicating such connection.
  - (3) **Other provisions—** The provisions of [section 1395w–134(c) of this title](/usc/42/1395w–134.md?p=c) shall apply to the requirements under this section.
  - (4) **Special treatment under out-of-pocket rule—** In applying [section 1395w–102(b)(4)(C)(ii) of this title](/usc/42/1395w–102.md?p=b-4-C-ii), expenses incurred under a [State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17) may be counted toward the annual out-of-pocket threshold.
  - (5) **Construction—** Nothing in this section shall be construed as requiring a [State Pharmaceutical Assistance Program](/usc/42/1395w–151.md?p=a-17) to coordinate or provide financial assistance with respect to any part D plan.
- (d) **Facilitation of transition and coordination with State Pharmaceutical Assistance Programs—**
  - (1) **Transitional grant program—** The [Secretary](/usc/42/1301.md?p=a-6) shall provide payments to [State Pharmaceutical Assistance Programs](/usc/42/1395w–151.md?p=a-17) with an application approved under this subsection.
  - (2) **Use of funds—** Payments under this section may be used by a Program for any of the following:
    - (A) Educating [part D eligible individuals](/usc/42/1395w–151.md?p=a-4) enrolled in the Program about the prescription [drug](/usc/42/11851.md?p=4) coverage available through part D plans under this part.
    - (B) Providing technical assistance, phone support, and counseling for such enrollees to facilitate selection and enrollment in such plans.
    - (C) Other activities designed to promote the effective coordination of enrollment, coverage, and payment between such Program and such plans.
  - (3) **Allocation of funds—** Of the amount appropriated to carry out this subsection for a [fiscal year](/usc/42/619.md?p=3), the [Secretary](/usc/42/1301.md?p=a-6) shall allocate payments among Programs that have applications approved under [paragraph (4)](#d-4) for such [fiscal year](/usc/42/619.md?p=3) in proportion to the number of enrollees enrolled in each such Program as of October 1, 2003.
  - (4) **Application—** No payments may be made under this subsection except pursuant to an application that is submitted and approved in a time, manner, and form specified by the [Secretary](/usc/42/1301.md?p=a-6).
  - (5) **Funding—** Out of any funds in the Treasury not otherwise appropriated, there are appropriated for each of [fiscal years](/usc/42/619.md?p=3) 2005 and 2006, $62,500,000 to carry out this subsection.

## Source credit

(Aug. 14, 1935, ch. 531, title XVIII, § 1860D–23, as added Pub. L. 108–173, title I, § 101(a)(2), Dec. 8, 2003, 117 Stat. 2128.)