Sec. 103. Providing for variation in payment for certain drugs covered under part B of the Medicare program

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Section 1847A(b) of the Social Security Act (42 U.S.C. 1395w–3a(b)) is amended— in paragraph (1)— in subparagraph (A), by inserting after or 106 percent the following: (or, for a multiple source drug (other than autologous cellular immunotherapy) furnished on or after January 1, 2021, the applicable percent specified in paragraph (9)(A) for the drug and quarter involved) ; and in subparagraph

(B)of paragraph (1), by inserting after 106 percent the following: (or, for a single source drug or biological (other than autologous cellular immunotherapy) furnished on or after January 1, 2021, the applicable percent specified in paragraph (9)(A) for the drug or biological and quarter involved) ; and by adding at the end the following new paragraph: Subject to clauses (ii), with respect to a drug or biological furnished in a calendar quarter beginning on or after January 1, 2021, if the Secretary determines that the percentile rank of a drug or biological under subparagraph (B)(i)(III), with respect to per beneficiary allowed charges for all such drugs or biologicals, is— at least equal to the 85th percentile, the applicable percent for the drug for such quarter under this subparagraph is 104 percent; at least equal to the 70th percentile, but less than the 85th percentile, such applicable percent is 106 percent; at least equal to the 50th percentile, but less than the 70th percentile, such applicable percent is 108 percent; or less than the 50th percentile, such applicable percent is 110 percent. Subject to clause (iii), in the case of a drug or biological furnished for which the amount of payment is determined under subparagraph

(A)or

(B)of paragraph

(1)and not under subsection (c)(4), for calendar quarters during a period in which data are not sufficiently available to compute a per beneficiary allowed charges for the drug or biological, the applicable percent is 106 percent. With respect to a calendar quarter beginning on or after January 1, 2021, for drugs and biologicals for which the amount of payment is determined under subparagraph

(A)or

(B)of paragraph (1), except for drugs or biologicals for which data are not sufficiently available, the Secretary shall— compute the per beneficiary allowed charges (as defined in subparagraph

(C)) for each such drug or biological; adjust such per beneficiary allowed charges for the quarter, to the extent provided under subparagraph (D); and array such adjusted per beneficiary allowed charges for all such drugs or biologicals from high to low and rank such drugs or biologicals by percentile of such arrayed per beneficiary allowed charges. The Secretary shall make the computations under clause (i)(I) every 6 months (or, if necessary, as determined by the Secretary, every 9 or 12 months) and such computations shall apply to succeeding calendar quarters until a new computation has been made. For purposes of this paragraph, the term applicable data period means the most recent period for which the data necessary for making the computations under clause

(i)are available, as determined by the Secretary. In this paragraph, the term per beneficiary allowed charges means, with respect to a drug or biological for which the amount of payment is determined under subparagraph

(A)or

(B)of paragraph (1)— the allowed charges for the drug or biological for which payment is so made for the applicable data period, as estimated by the Secretary; divided by the number of individuals for whom any payment for the drug or biological was made under paragraph

(1)for the applicable data period, as estimated by the Secretary. In applying this paragraph for a particular calendar quarter, the Secretary shall adjust the per beneficiary allowed charges for a drug or biological by multiplying such per beneficiary allowed charges under subparagraph

(C)for the applicable data period by the ratio of— the average sales price for the drug or biological for the most recent calendar quarter used under subsection (c)(5)(B); to the average sales price for the drug or biological for the calendar quarter (or the weighted average for the quarters involved) included in the applicable data period. . Section 1847A(g) of the Social Security Act is amended— by striking and at the end of paragraph (4); by striking the period at the end of paragraph

(5)and inserting ; and ; and by adding at the end the following new paragraph: the determination of per beneficiary allowed charges of drugs or biologicals and ranking of such charges under subsection (b)(9). .

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42 USC 1395w–3a(b)

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Sec. 103

Providing for variation in payment for certain drugs covered under part B of the Medicare program

Cite42 USC 1395w–3a(b)

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