Sec. 5. Increasing the use of real-time benefit tools to lower beneficiary costs

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Section 1860D–4 of the Social Security Act ( 42 U.S.C. 1395w–104 ) is amended— by redesignating subsection

(m)(relating to program integrity transparency measures), as added by section 6063(c) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act ( Public Law 115–271 ), as subsection (n); and by adding at the end the following new subsection: After the Secretary has adopted a standard under paragraph

(3)for electronic real-time benefit tools, and at a time determined appropriate by the Secretary, a PDP sponsor of a prescription drug plan shall implement one or more of such tools that meet the requirements described in paragraph (2). For purposes of paragraph (1), the requirements described in this paragraph, with respect to an electronic real-time benefit tool, are that the tool is capable of— integrating with electronic prescribing and electronic health record systems of prescribing health care professionals for the transmission of eligibility and formulary and benefit information in real time to such professionals; and with respect to a covered part D drug, transmitting such information specific to an individual enrolled in a prescription drug plan, including the following: A list of any clinically appropriate alternatives to such drug included in the formulary of such plan. Cost-sharing information and the negotiated price for such drug and such alternatives at— multiple pharmacy options, including the individual’s preferred pharmacy and, as applicable, other retail pharmacies and a mail order pharmacy; and the formulary status of such drug and such alternatives and any prior authorization or other utilization management requirements applicable to such drug and such alternatives included in the formulary of such plan. In order to be treated (for purposes of this subsection) as an electronic real-time benefit tool described in paragraph (1), such tool shall comply with technical standards adopted by the Secretary in consultation with the National Coordinator for Health Information Technology, the National Council for Prescription Drug Programs, other standard setting organizations determined appropriate by the Secretary, and stakeholders including PDP sponsors, Medicare Advantage organizations, health care professionals, and health information technology software vendors. Nothing in this subsection shall be construed to prohibit the application of paragraph (b)(7) of section 423.160 of title 42, Code of Federal Regulations, as is to be added to such section pursuant to the final rule published in the Federal Register on May 23, 2019, and titled Modernizing Part D and Medicare Advantage To Lower Drug Prices and Reduce Out-of-Pocket Expenses (84 Fed. Reg. 23832 through 23884). . Section 3000(13) of the Public Health Service Act ( 42 U.S.C. 300jj(13) ) is amended— in subparagraph (A), by striking and at the end; in subparagraph (B), by striking the period and inserting ; and ; and by adding at the end the following: includes, or is capable of including, a real-time benefit tool that conveys patient-specific real-time cost and coverage information with respect to prescription drugs that, with respect to any health information technology certified for electronic prescribing, the technology shall be capable of incorporating the information described in clauses

(i)and

(ii)of paragraph (2)(B) of section 1860D–4(o) of the Social Security Act at a time specified by the Secretary but not before the Secretary adopts a standard for such tools as described in paragraph

(1)of such section. . Section 1848(q)(2)(B)(iii)(IV) of the Social Security Act ( 42 U.S.C. 1395w–4(q)(2)(B)(iii)(IV) ) is amended by adding at the end the following new sentence: This subcategory shall include as an activity option, beginning with the performance period starting on January 1, 2021, use of a real-time benefit tool as described in 1860D–4(o). .

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