Sec. 7. Requiring prescription drug plan sponsors to include real-time benefit information as part of such sponsor’s electronic prescription program under the Medicare program

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Section 1860D–4(e)(2) of the Social Security Act ( 42 U.S.C. 1395w–104(e)(2) ) is amended— in subparagraph (D), by striking To the extent and inserting Except as provided in subparagraph (F), to the extent ; and by adding at the end the following new subparagraph: Not later than January 1, 2021, the program shall implement real-time benefit tools that are capable of integrating with a prescribing health care professional’s electronic prescribing or electronic health record system for the transmission of formulary and benefit information in real time to prescribing health care professionals.

With respect to a covered part D drug, such tools shall be capable of transmitting such information specific to an individual enrolled in a prescription drug plan. Such information shall include the following: A list of any clinically-appropriate alternatives to such drug included in the formulary of such plan. Cost-sharing information for such drug and such alternatives, including a description of any variance in cost sharing based on the pharmacy dispensing such drug or such alternatives.

Information relating to whether such drug is included in the formulary of such plan and any prior authorization or other utilization management requirements applicable to such drug and such alternatives so included. The provisions of subclauses

(I)and

(II)of clause

(ii)of subparagraph

(E)shall apply to an electronic transmission described in clause

(i)in the same manner as such provisions apply with respect to an electronic transmission described in clause

(i)of such subparagraph. The program shall be deemed to be in compliance with clause

(i)for 2021 if the program complies with the provisions of section 423.160(b)(7) of title 42, Code of Federal Regulations (or a successor regulation), for such year. Nothing in this subparagraph shall be construed as to allow a real time benefits tool to steer an individual, without the consent of the individual, to a particular pharmacy or pharmacy setting over their preferred pharmacy setting nor prohibit the designation of a preferred pharmacy under such tool. .

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42 USC 1395w–104(e)(2)

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Sec. 7

Requiring prescription drug plan sponsors to include real-time benefit information as part of such sponsor’s electronic prescription program under the Medicare program

Cite42 USC 1395w–104(e)(2)

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