Sec. 2. Establishing PDP safety program to prevent fraud and abuse in Medicare prescription drug plans

556 words·~3 min read·/bill/113/hr/3392/ih/section-2

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 1860D–4(c) of the Social Security Act ( 42 U.S.C. 1395w–104(c) ) is amended— in paragraph (1)(D)— by inserting after , designed to program ; and by inserting , that includes the procedures described in paragraph

(4)after waste ; and by adding at the end the following: A PDP sponsor (or an MA organization offering an MA–PD plan) shall have in place procedures designed— to identify an individual who has obtained coverage for a covered part D drug that is a frequently abused schedule II, III, IV, or V controlled substance, as determined in accordance with utilization guidelines established by the Secretary and the sponsor (or MA organization), and to notify such individuals that they have been so identified; to contract with pharmacies authorized to dispense such controlled substances to create a safe pharmacy network that meets the criteria specified in subparagraph (C); taking into account the location of the individual’s residence (or residences), work site, mobility, and other relevant factors, to limit coverage to schedule II, III, IV, or V controlled substances for some or all classes of covered part D drugs for an individual identified under clause

(i)(or under subparagraph (B)) to drugs dispensed by one or more pharmacies contracted with under clause (ii); to provide to the Secretary the name, and other information that the Secretary may require, of individuals so identified and of the fact of such individual’s disenrollment (if any) from the plan of the sponsor (or the MA–PD plan offered by the MA organization); to provide for an appeals process whereby an individual so identified may appeal such identification on the basis that the identification was not appropriate; to provide for a process whereby an individual so identified may petition for the termination of such identification on the basis that the limitation on coverage is no longer necessary to prevent fraud and abuse by the individual; and to provide that coverage shall be provided for a schedule II, III, IV, or V controlled substance only if it prescribed in accordance with an electronic prescribing program under subsection (e), except in such exceptional circumstances as the Secretary may permit. The Secretary shall share information, with respect to the identity of an individual identified under subparagraph (A)(i) who disenrolls from a plan under subparagraph (A)(iv), with a PDP sponsor (or MA organization) that subsequently enrolls such individual under another plan in order that the provisions of subparagraph (A)(iii) would apply under such subsequent enrollment. The criteria specified in this subparagraph for a safe pharmacy network are the following: The pharmacies in the network are able to properly monitor the usage of schedule II, III, IV, and V controlled substances. Such pharmacies and network meet such other drug safety criteria as the Secretary or the PDP sponsor (or MA organization) determines to be appropriate, such as use of a State prescription drug monitoring program, if such a program is available in the State. . Section 1860D–1(b)(3)(D) of the Social Security Act ( 42 U.S.C. 1395w–101(b)(3)(D) ) is amended by inserting , subject to such limits as the Secretary may establish for individuals identified pursuant to section 1860D–4(c)(4)(A)(i) after the Secretary . The amendments made by this section shall apply with respect to plan years beginning after the date that is 8 months after the date of the enactment of this Act.

Connections2 off-index

2 references not yet in our index

42 USC 1395w–104(c)
42 USC 1395w–101(b)(3)(D)

Citation graph

cites case law

Sec. 2

Establishing PDP safety program to prevent fraud and abuse in Medicare prescription drug plans

Cite42 USC 1395w–104(c)

Cite42 USC 1395w–101(b)(3)(D)

Cites 2Cited by 0 across 0 sources