USC Subpart 5

USC Subpart 5
in effect

42 U.S.C. § 1395w–151 Definitions; treatment of references to provisions in part C

(a) DefinitionsFor purposes of this part:(1) Basic prescription drug coverageThe term “basic prescription drug coverage” is defined in section 1395w–102(a)(3) of this title. (2) Covered part D drugThe term “covered part D drug” is defined in section 1395w–102(e) of this title. (3) Creditable prescription drug coverageThe term “creditable prescription drug coverage” has the meaning given such term in section 1395w–113(b)(4) of this title. (4) Part D eligible individualThe term “part D eligible individual” has the meaning given such term in section 1395w–101(a)(3)(A) of this title.11 See References in Text note below. (5) Fallback prescription drug planThe term “fallback prescription drug plan” has the meaning given such term in section 1395w–111(g)(4) of this title. (6) Initial coverage limitThe term “initial coverage limit” means such limit as established under section 1395w–102(b)(3) of this title for a year before 2025, or, in the case of coverage that is not standard prescription drug coverage, the comparable limit (if any) established under the coverage for such year. (7) Insurance riskThe term “insurance risk” means, with respect to a participating pharmacy, risk of the type commonly assumed only by insurers licensed by a State and does not include payment variations designed to reflect performance-based measures of activities within the control of the pharmacy, such as formulary compliance and generic drug substitution. (8) MA planThe term “MA plan” has the meaning given such term in section 1395w–101(a)(3)(B) of this title.1 (9) MA–PD planThe term “MA–PD plan” has the meaning given such term in section 1395w–101(a)(3)(C) of this title.1 (10) Medicare Prescription Drug AccountThe term “Medicare Prescription Drug Account” means the Account created under section 1395w–116(a) of this title. (11) PDP approved bidThe term “PDP approved bid” has the meaning given such term in section 1395w–113(a)(6) of this title. (12) PDP regionThe term “PDP region” means such a region as provided under section 1395w–111(a)(2) of this title. (13) PDP sponsorThe term “PDP sponsor” means a nongovernmental entity that is certified under this part as meeting the requirements and standards of this part for such a sponsor. (14) Prescription drug planThe term “prescription drug plan” means prescription drug coverage that is offered—(A) under a policy, contract, or plan that has been approved under section 1395w–111(e) of this title; and (B) by a PDP sponsor pursuant to, and in accordance with, a contract between the Secretary and the sponsor under section 1395w–112(b) of this title. (15) Qualified prescription drug coverageThe term “qualified prescription drug coverage” is defined in section 1395w–102(a)(1) of this title. (16) Standard prescription drug coverageThe term “standard prescription drug coverage” is defined in section 1395w–102(b) of this title. (17) State Pharmaceutical Assistance ProgramThe term “State Pharmaceutical Assistance Program” has the meaning given such term in section 1395w–133(b) of this title. (18) Subsidy eligible individualThe term “subsidy eligible individual” has the meaning given such term in section 1395w–114(a)(3)(A) of this title. (b) Application of part C provisions under this partFor purposes of applying provisions of part C under this part with respect to a prescription drug plan and a PDP sponsor, unless otherwise provided in this part such provisions shall be applied as if—(1) any reference to an MA plan included a reference to a prescription drug plan; (2) any reference to an MA organization or a provider-sponsored organization included a reference to a PDP sponsor; (3) any reference to a contract under section 1395w–27 of this title included a reference to a contract under section 1395w–112(b) of this title; (4) any reference to part C included a reference to this part; and (5) any reference to an election period under section 1395w–21 of this title were a reference to an enrollment period under section 1395w–101 of this title.

42 U.S.C. § 1395w–152 Miscellaneous provisions

(a) Access to coverage in territoriesThe Secretary may waive such requirements of this part, including section 1395w–103(a)(1) of this title, insofar as the Secretary determines it is necessary to secure access to qualified prescription drug coverage for part D eligible individuals residing in a State (other than the 50 States and the District of Columbia). (b) Application of demonstration authorityThe provisions of section 402 of the Social Security Amendments of 1967 (Public Law 90–248) shall apply with respect to this part and part C in the same manner it applies with respect to parts A and B, except that any reference with respect to a Trust Fund in relation to an experiment or demonstration project relating to prescription drug coverage under this part shall be deemed a reference to the Medicare Prescription Drug Account within the Federal Supplementary Medical Insurance Trust Fund. (c) Coverage gap rebate for 2010(1) In generalIn the case of an individual described in subparagraphs (A) through (D) of section 1395w–114a(g)(1) of this title who as of the last day of a calendar quarter in 2010 has incurred costs for covered part D drugs so that the individual has exceeded the initial coverage limit under section 1395w–102(b)(3) of this title for 2010, the Secretary shall provide for payment from the Medicare Prescription Drug Account of $250 to the individual by not later than the 15th day of the third month following the end of such quarter. (2) LimitationThe Secretary shall provide only 1 payment under this subsection with respect to any individual. (d) Treatment of certain complaints for purposes of quality or performance assessmentIn conducting a quality or performance assessment of a PDP sponsor, the Secretary shall develop or utilize existing screening methods for reviewing and considering complaints that are received from enrollees in a prescription drug plan offered by such PDP sponsor and that are complaints regarding the lack of access by the individual to prescription drugs due to a drug management program for at-risk beneficiaries. (e) Essential retail pharmacies(1) In generalWith respect to plan years beginning on or after January 1, 2028, the Secretary shall publish reports, at least once every 2 years until 2034, and periodically thereafter, that provide information, to the extent feasible, on—(A) trends in ingredient cost reimbursement, dispensing fees, incentive payments and other fees paid by PDP sponsors offering prescription drug plans and MA organizations offering MA–PD plans under this part to essential retail pharmacies (as defined in paragraph (2)) with respect to the dispensing of covered part D drugs, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies; (B) trends in amounts paid to PDP sponsors offering prescription drug plans and MA organizations offering MA–PD plans under this part by essential retail pharmacies with respect to the dispensing of covered part D drugs, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies; (C) trends in essential retail pharmacy participation in pharmacy networks and preferred pharmacy networks for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies; (D) trends in the number of essential retail pharmacies, including variation in such trends by geographic region or other factors; (E) a comparison of cost-sharing for covered part D drugs dispensed by essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part and cost-sharing for covered part D drugs dispensed by other network pharmacies for such plans located in similar geographic areas that are not essential retail pharmacies; (F) a comparison of the volume of covered part D drugs dispensed by essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part and such volume of dispensing by network pharmacies for such plans located in similar geographic areas that are not essential retail pharmacies, including information on any patterns or trends in such comparison specific to certain types of covered part D drugs, such as generic drugs or drugs specified as specialty drugs by a PDP sponsor under a prescription drug plan or an MA organization under an MA–PD plan; and (G) a comparison of the information described in subparagraphs (A) through (F) between essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors under this part and essential retail pharmacies that are network pharmacies for MA–PD plans offered by MA organizations under this part. (2) Definition of essential retail pharmacyIn this subsection, the term “essential retail pharmacy” means, with respect to a plan year, a retail pharmacy that—(A) is not a pharmacy that is an affiliate as defined in paragraph (4); and (B) is located in—(i) a rural area in which there is no other retail pharmacy within 10 miles, as determined by the Secretary; (ii) a suburban area in which there is no other retail pharmacy within 2 miles, as determined by the Secretary; or (iii) an urban area in which there is no other retail pharmacy within 1 mile, as determined by the Secretary. (3) List of essential retail pharmacies(A) Publication of list of essential retail pharmaciesFor each plan year (beginning with plan year 2028), the Secretary shall publish, on a publicly available internet website of the Centers for Medicare & Medicaid Services, a list of retail pharmacies that meet the criteria described in subparagraphs (A) and (B) of paragraph (2) to be considered an essential retail pharmacy. (B) Required submissions from PDP sponsorsFor each plan year (beginning with plan year 2028), each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan shall submit to the Secretary, for the purposes of determining retail pharmacies that meet the criterion specified in subparagraph (A) of paragraph (2), a list of retail pharmacies that are affiliates of such sponsor or organization, or are affiliates of a pharmacy benefit manager acting on behalf of such sponsor or organization, at a time, and in a form and manner, specified by the Secretary. (C) Reporting by PDP sponsors and MA organizationsFor each plan year beginning with plan year 2027, each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan under this part shall submit to the Secretary information on incentive payments and other fees paid by such sponsor or organization to pharmacies, insofar as any such payments or fees are not otherwise reported, at a time, and in a form and manner, specified by the Secretary. (D) ImplementationNotwithstanding any other provision of law, the Secretary may implement this paragraph by program instruction or otherwise. (E) Nonapplication of Paperwork Reduction ActChapter 35 of title 44 shall not apply to the implementation of this paragraph. (4) Definition of affiliate; pharmacy benefit managerIn this subsection, the terms “affiliate” and “pharmacy benefit manager” have the meaning given those terms in section 1395w–112(h)(7) of this title. (f) Biennial report on enforcement and oversight of pharmacy access requirements(1) In generalNot later than 2 years after February 3, 2026, and at least once every 2 years thereafter, the Secretary shall publish a report on enforcement and oversight actions and activities undertaken by the Secretary with respect to the requirements under section 1395w–104(b)(1) of this title. (2) LimitationA report under paragraph (1) shall not disclose—(A) identifiable information about individuals or entities unless such information is otherwise publicly available; or (B) trade secrets with respect to any entities.

42 U.S.C. § 1395w–153 Condition for coverage of drugs under this part

(a) In generalIn order for coverage to be available under this part for covered part D drugs (as defined in section 1395w–102(e) of this title) of a manufacturer, the manufacturer must—(1) participate in—(A) for 2011 through 2024, the Medicare coverage gap discount program under section 1395w–114a of this title; and (B) for 2025 and each subsequent year, the manufacturer discount program under section 1395w–114c of this title; (2) have entered into and have in effect—(A) for 2011 through 2024, an agreement described in subsection (b) of section 1395w–114a of this title with the Secretary; and (B) for 2025 and each subsequent year, an agreement described in subsection (b) of section 1395w–114c of this title with the Secretary; and (3) have entered into and have in effect, under terms and conditions specified by the Secretary, a contract with a third party that the Secretary has entered into a contract with under subsection (d)(3) of section 1395w–114a of this title. (b) Effective dateParagraphs (1)(A), (2)(A), and (3) of subsection (a) shall apply to covered part D drugs dispensed under this part on or after January 1, 2011, and before January 1, 2025, and paragraphs (1)(B) and (2)(B) of such subsection shall apply to covered part D drugs dispensed under this part on or after January 1, 2025. (c) Authorizing coverage for drugs not covered under agreements(1) In generalSubject to paragraph (2), subsection (a) shall not apply to the dispensing of a covered part D drug if—(A) the Secretary has made a determination that the availability of the drug is essential to the health of beneficiaries under this part; or (B) the Secretary determines that in the period beginning on January 1, 2011, and 11 So in original. Probably should be followed by “ending on”. December 31, 2011, there were extenuating circumstances. (2) ExceptionParagraph (1)(A) shall not apply to a covered part D drug of a manufacturer for any period described in section 5000D(c)(1) of the Internal Revenue Code of 1986 with respect to the manufacturer. (d) Definition of manufacturerIn this section, the term “manufacturer” has the meaning given such term in section 1395w–114a(g)(5) of this title.

42 U.S.C. § 1395w–154 Improved Medicare prescription drug plan and MA–PD plan complaint system

(a) In generalThe Secretary shall develop and maintain a complaint system, that is widely known and easy to use, to collect and maintain information on MA–PD plan and prescription drug plan complaints that are received (including by telephone, letter, e-mail, or any other means) by the Secretary (including by a regional office of the Department of Health and Human Services, the Medicare Beneficiary Ombudsman, a subcontractor, a carrier, a fiscal intermediary, and a Medicare administrative contractor under section 1395kk–1 of this title) through the date on which the complaint is resolved. The system shall be able to report and initiate appropriate interventions and monitoring based on substantial complaints and to guide quality improvement. (b) Model electronic complaint formThe Secretary shall develop a model electronic complaint form to be used for reporting plan complaints under the system. Such form shall be prominently displayed on the front page of the Medicare.gov Internet website and on the Internet website of the Medicare Beneficiary Ombudsman. (c) Annual reports by the SecretaryThe Secretary shall submit to Congress annual reports on the system. Such reports shall include an analysis of the number and types of complaints reported in the system, geographic variations in such complaints, the timeliness of agency or plan responses to such complaints, and the resolution of such complaints. (d) DefinitionsIn this section:(1) MA–PD planThe term “MA–PD plan” has the meaning given such term in section 1395w–151(a)(9) of this title. (2) Prescription drug planThe term “prescription drug plan” has the meaning given such term in section 1395w–151(a)(14) of this title. (3) SecretaryThe term “Secretary” means the Secretary of Health and Human Services. (4) SystemThe term “system” means the plan complaint system developed and maintained under subsection (a).

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