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Pennsylvania Statutes Title 72 P.S. Taxation and Fiscal Affairs § 3761-534. Coordination of benefits

Current as of January 01, 2026 | Updated by Findlaw Staff

(a) General coordination.--In addition to the specific provisions of subsection (b), the department shall establish standards and minimum requirements it deems necessary to allow for the coordination of benefits between the program and Part D.

(b) Specific coordination provisions.--The following provisions shall apply to claimants who are also Part D enrollees:

(1) The primary payor shall be the PDP or the Medicare Advantage Prescription Drug Plan, as appropriate.

(2) Part D enrollees shall be required to utilize providers authorized by their PDPs or Medicare Advantage Prescription Drug Plans.

(3) The program shall pay the premium assessed by a PACE enrollee's PDP or, with respect to the prescription drug plan, Medicare Advantage Prescription Drug Plan in an amount not to exceed the regional benchmark premium and any copayments in excess of those set forth in section 509.  1

(4) Part D enrollees enrolled in PACENET shall pay the Part D premiums charged by their PDP or, with respect to the prescription drug plan, Medicare Advantage Prescription Drug Plan and the program shall pay any copayments in excess of those set forth in section 519.  2  A claimant enrolled in a PDP shall not be required to pay a monthly premium for any month the claimant is not dispensed a prescription drug.

(5) For Part D enrollees enrolled in PACE who are not eligible for LIS, PACE shall reimburse Part D providers for prescription drugs in any noncoverage phase of Part D. For Part D enrollees enrolled in PACENET, PACENET shall reimburse Part D providers for prescription drugs in any noncoverage phase of Part D.

(6) The provisions of Chapter 7   3 shall apply to all payments made by the program in the noncoverage phase.

(7) The department shall advise a claimant on the various benefits and drugs provided by each PDP approved by the department as follows:

(i) Analyze the claimant's eligibility for and assist the claimant in applying for LIS.

(ii) Identify the claimant's prescription drug needs and preferred pharmacy.

(iii) Assist the claimant in enrolling in the PDP that best fits the claimant's prescription drug needs.

(iv) File and pursue appeals in accordance with CMS regulations with a claimant's Part D plan on the claimant's behalf to request exceptions to the plan's tiered cost-sharing structure or to request a nonformulary Part D drug.

(8) Notwithstanding the provisions of sections 511 and 513(a),  4 for purposes of coordination of benefits with Medicare Part D plans and to minimize disruption to enrollees, the program shall be authorized to reimburse Part D providers, including mail-order pharmacies, for more than a 30-day supply of prescription drugs.

(c) Contracts.--The department is authorized to enter into contracts with Part D plans to provide for prescription drugs to Part D enrollees through Part D pursuant to this subchapter.  A Part D plan selected by the department shall meet all of the following requirements:

(1) The Part D plan has a retail pharmacy network that includes at least 90% of the pharmacies in the PACE network.

(2) The Part D plan has a premium at or below the regional benchmark premium.

(c.1) Authorization.--The department may pay the LEP of Part D enrollees in excess of the regional benchmark premium.

(d) Rebates.--The department may only receive rebates as provided in Chapter 7 where the program is the only payor for a Part D enrollee's covered prescription drugs.

1  72 P.S. § 3761-509.
2  72 P.S. § 3761-519.
3  72 P.S. § 3761-701 et seq.
4  72 P.S. §§ 3761-511, 3761-513.
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Cite this article: FindLaw.com - Pennsylvania Statutes Title 72 P.S. Taxation and Fiscal Affairs § 3761-534. Coordination of benefits - last updated January 01, 2026 | https://codes.findlaw.com/pa/title-72-ps-taxation-and-fiscal-affairs/pa-st-sect-72-3761-534/

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