Tip for PAP Attestation

Some PAPs require Medicare beneficiaries to demonstrate they cannot afford their medications even with Part D coverage

Tip for PAP Attestation

The attestation must be honest and accurate — misrepresentation can result in program termination

Tip for PAP Attestation

If you have Part D coverage, the PAP may require you to use Part D first and apply the PAP only to remaining costs

Financial Assistancemoderate

PAP Attestation Form (CMS)

PAP Attestation · CMS

Attestation that the Patient Assistance Program operates outside the Part D benefit to ensure separateness. PAP assistance does not count toward True Out-of-Pocket costs (TrOOP).

Form Details

Total fields: 25
Auto-fillable: 16 (64%)
Time without BeneFill: 20 minutes
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Time saved: 14 minutes
Filled by: patient
Frequency: annual

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Where to Submit This Form

📬

Mail to CMS or to the pharmaceutical manufacturer as directed

This attestation may be required by certain PAPs for Medicare beneficiaries to confirm they have no other coverage.

📠

Fax to the manufacturer's PAP as directed on the form

Filing Deadline

Submit with the PAP application or renewal. Must be current — typically valid for 12 months.

Required Attachments

📎 Signed CMS attestation form
📎 Documentation of Medicare enrollment (Medicare card copy)
📎 Evidence that the beneficiary has no other prescription drug coverage or that existing coverage is inadequate

Processing Time

Processed as part of the PAP application — 2-6 weeks total.

What Happens Next

The attestation is filed with the PAP application. Once approved, medications are provided at no cost or reduced cost through the manufacturer's program.

Tips for This Form

✓ Some PAPs require Medicare beneficiaries to demonstrate they cannot afford their medications even with Part D coverage
✓ The attestation must be honest and accurate — misrepresentation can result in program termination
✓ If you have Part D coverage, the PAP may require you to use Part D first and apply the PAP only to remaining costs
✓ Contact Medicare SHIP counselors for help navigating PAP applications as a Medicare beneficiary

More Financial Assistance Forms

Patient Assistance Program Enrollment

PAP Enrollment (manufacturer-specific) · Pharmaceutical Manufacturers (Pfizer, Lilly, Merck, J&J, AbbVie, etc.)

Application for free or reduced-cost medications for uninsured or underinsured patients. Requires income documentation and prescriber attestation. Each manufacturer has its own form and eligibility criteria.

Manufacturer Copay Card / Coupon Enrollment

Copay Card (manufacturer-specific) · Pharmaceutical Manufacturers

Enrollment for manufacturer copay reduction programs for commercially insured patients. NOT available to Medicare, Medicaid, or other federal program beneficiaries. Some insurers have accumulator adjustment programs that prevent copay card amounts from counting toward deductible.

340B OPAIS Registration

340B OPAIS · HRSA Office of Pharmacy Affairs

Online registration in the 340B Office of Pharmacy Affairs Information System. Required for covered entities (FQHCs, hospitals, etc.) before purchasing 340B-priced drugs. Requires supporting documentation for hospital classification.

340B Annual Recertification

340B Recertification · HRSA

Annual recertification of eligibility to participate in the 340B program. Failure to complete results in program termination. Authorizing Official must verify compliance with all program requirements.

State Pharmaceutical Assistance Program Application

SPAP Application (state-specific, e.g., NJ PAAD, NY EPIC, PA PACE) · State Pharmaceutical Assistance Programs

Application for state-funded prescription drug assistance. Eligibility typically based on age, income, and residency. Available in 20+ states. May coordinate with Medicare Part D for additional savings.

Extra Help / Low-Income Subsidy (LIS) Application

SSA-1020 · Social Security Administration

Application for Extra Help (Low-Income Subsidy) with Medicare Part D prescription drug costs. Reduces premiums, deductibles, and copayments for qualifying beneficiaries. Can save an average of $5,300 per year.

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