Improving health is our policy
As amended by section 1101 of HCERA, effective 2011, phases in closure of the Part D “donut hole” by requiring 50% discounts on brand name and generic drugs to enrollees in that component of the benefit. Discount increases to 75% by 2020. Provides $250 rebate for all Medicare Part D
enrollees in the donut hole in 2010.
On April 30, 2010, CMS issued draft guidance to Part D plans regarding the coverage gap discount program. On May 26, 2010, CMS released a notice regarding model agreements between CMS and drug manufacturers. Additional information relating to Part D for manufacturers is available here. This provision was formally codified in the final MA/Part D rule issued on April 15, 2011 (see pp. 21478-80).
On February 15, 2013, CMS released its Calendar Year (CY) 2014 Medicare Advantage (MA) Advanced Notice and Draft Call Letter; this included discussion of how, pursuant to the ACA, Part D enrollees with liability in the “donut hole” will receive coverage and discounts of 52.5% on covered brand name drugs and 28% on covered generic drugs. In a related development, on February 7, HHS released an annual ACA-related report, a component of which indicated that more than 3.5 million beneficiaries in the “donut hole” saved $2.5 billion in 2012 alone, or an average of $706 per beneficiary.
On April 1, 2013, CMS released the Announcement of Calendar Year 2014 Medicare Advantage (MA) and Medicare Part D Final Call Letter reflecting several ACA-driven changes to MA payment, including the application of a 4.91 percent coding intensity adjustment – which also reflects an increase by the ATRA of 2012 – as well as CMS’s use of its authority to deny MA plan bids based on changes in cost-sharing or benefits. Implementation continues of the new ACA blended benchmark and related policies, as well as of the Star rating system and Quality Bonus Demonstration. The agency indicated it may issue future guidance on shared decision-making. CMS also notes that in 2014, “plan liability in the coverage gap for non-applicable (generic) drugs increases by 7 percent.” Please see the CMS press release for more details.
On July 23, 2013, HHS posted its updated semiannual regulatory agenda. Per the updated agenda, consistent with the ACA requirements (at sections 2501, 2503, and 3301, as well as section 1206 of the reconciliation “side car”), CMS tentatively anticipates issuing a final rule on Medicaid reimbursement of outpatient drugs (CMS-2345-F) in January 2014. Per the agenda listing, “this final rule revises requirements pertaining to Medicaid reimbursement for covered outpatient drugs…[and] also revises other requirements related to covered outpatient drugs, including key aspects of Medicaid coverage, payment, and the drug rebate program.”
On July 22, HHS updated its Semiannual Regulatory Agenda and noted that it anticipates issuing a final rule in January 2014 on Outpatient Drugs (CMS-2345-F) (Section 610 Review) (ID: 0938–AQ41) that, according to CMS, is consistent with ACA requirements at various sections including 3301.
On July 29, CMS released data indicating that, since the ACA’s enactment, 6.6 million Medicare beneficiaries have saved $7 billion in out-of-pocket prescription drug costs in the Part D donut hole, averaging $1,061 per beneficiary. CMS’s press release is available here.
On September 19, 2013, HHS announced that the average CY14 MA premium will be $32.60, an increase of $1.64 over last year. HHS in its press released indicated that, “since the passage of the [ACA], average MA premiums are down by 9.8%.” HHS also reiterated the impact of the ACA provision that closes the “donut hole” and the general savings that have been achieved under Part D.
On January 6, 2014, CMS issued a proposed rule delineating Contract Year 2015 MA and Part D policy and technical changes. The rule proposes, among other things, to limit and redefine, based on new criteria, Part D’s protected drug classes to initially include anticonvulsants, antiretrovirals and antineoplastics — but not antidepressants and immunosuppressants – as “drug categories and classes of clinical concern” for the 2015 coverage year. The rule addresses each of these provisions of the ACA in some manner. A CMS fact sheet is available. Comments are due by March 7.
On February 21, 2014, CMS issued the CY15 Advanced Call Letter, which would produce a 6-7% cut from CY14. But the Agency adjusted the “normalization factor,” which could soften the blow by over 3%. But some analysts have suggested that, if CMS’ analysis is correct, then enrollee risk scores will dip in the coming years, negating the benefit of this change. Most other components of MA reimbursement are driven by statute, and CMS took no steps to alleviate those. While the combined growth factor is -1.9%, additional rate cuts from the ACA, the expiration of the 3-star bonus demonstration, and other changes further reduce MA plan comp. Comments are due March 7 at 6pm EST. The final rates will be released April 7.
On March 10, 2014, the Administration informed top Congressional leaders that it will not finalize some of the key changes to Part D that it had proposed in a draft regulation issued January 10. The elements of the Proposed Rule that the Administration will not finalize include: (1) Changes to the Six Protected Classes, which would have excluded mental health and immunosuppressive drugs from these protections (such as a requirement that plans cover all drugs in these classes), among other revisions; (2) Reductions in the number of plans a Part D sponsor may offer; (3) Limitations on the use of preferred pharmacies; and (4) New interpretation of the non-interference provisions. The Administration notes it will gather additional input and effectively reserves the right to advance changes in these areas in future years. But no changes will be made for the CY15 plan year. It will move forward with other elements of the Rule, as discussed in the Administration’s letter to Congressional members. A copy of the letter is available externally here.
On May 19, CMS issued a final rule on MA and Part D contract year 2015 technical changes. While the final rule codifies a number of fraud and abuse-related proposals, as signaled in an earlier letter to Congress the final rule does not adopt controversial proposed modifications to Part D protected drug classes or limitations on offering more than two Part D plans in a given region. The rule addresses each of these provisions of the ACA in some manner. A fact sheet is available here.
On July 29, HHS announced that over 8.2 million Medicare enrollees saved roughly $11.5 billion – for an average savings of $1,407 – on prescription drugs since the passage of the ACA provisions that aim to close the prescription drug coverage gap, or “donut hole.” State-specific information regarding these savings is available here.
On July 31, CMS announced lower than projected Medicare Part D premiums in 2015 as a result of what CMS attributes to be the effects of the ACA provisions aimed at closing the so-called ‘donut hole.’ Per the agency’s statement, average Part D drug plan premiums are set to increase by $1, to roughly $32 a month in 2015. CMS’ calculations are made by the agency’s Office of the Actuary and the 2015 projection is based on “bids submitted by drug and health plans for basic drug coverage for the 2015 benefit year.”
On October 2, the OIG issued aproposed rule delineating revisions to Medicare and Medicaid safe harbors under the anti-kickback statute, as well as amendments to civil monetary penalty (CMP) rules pertaining to beneficiary inducements and gainsharing. Comments are due by 5pm ET on Dec. 2, 2014.
On Jan. 21, 2016, CMS released a long-awaited final rule (fact sheet) on Medicaid reimbursement for covered outpatient drugs (CODs), including key dimensions of the Medicaid Drug Rebate Program.
On Feb. 24 HHS announced that over 9.4 million Medicare enrollees have saved roughly $15 billion – for an average per-beneficiary savings of $1,598 – on prescription drugs since the passage of the ACA provisions that aim to close the prescription drug coverage gap, or “donut hole.”
On Feb. 19, 2016, CMS released its estimates of the Calendar Year (CY) 2017 Medicare Advantage (MA) Advanced Notice and Draft Call Letter delineating the agency’s planned changes in the MA capitation rate and risk adjustment methodologies, as well as key policy changes under Part D. An agency press release is available here. CMS estimates that, on average, MA plans will see a +1.35 percent revenue increase relative to CY 2016 due to Advance Notice policies.
SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM. (a) CONDITION FOR COVERAGE OF DRUGS UNDER PART D.—Part D of Title XVIII of the Social Security Act (42 U.S.C. 1395w–101 et seq.), is amended by adding at the end the following new section: ‘‘CONDITION FOR COVERAGE OF DRUGS UNDER THIS PART ‘‘SEC. 1860D–43 ø42 U.S.C. 1395w–153¿. (a) IN GENERAL.—In order for coverage to be available under this part for covered part D drugs (as defined in section 1860D–2(e)) of a manufacturer, the manufacturer must— ‘‘(1) participate in the Medicare coverage gap discount program under section 1860D–14A; ‘‘(2) have entered into and have in effect an agreement described in subsection (b) of such section 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 such section. ‘‘(b) EFFECTIVE DATE.—Subsection (a) shall apply to covered part D drugs dispensed under this part on or after January 1, 2011. øAs revised by section 1101(b)(1)(A) of HCERA¿ ‘‘(c) AUTHORIZING COVERAGE FOR DRUGS NOT COVERED UNDER AGREEMENTS.—Subsection (a) shall not apply to the dispensing of a covered part D drug if – ‘‘(1) the Secretary has made a determination that the availability of the drug is essential to the health of beneficiaries under this part; or ‘‘(2) the Secretary determines that in the period beginning on January 1, 2011, and December 31, 2011, there were extenuating circumstances. øAs revised by section 1101(b)(1)(B) of HCERA¿ ‘‘(d) DEFINITION OF MANUFACTURER.—In this section, the term ‘manufacturer’ has the meaning given such term in section 1860D– 14A(g)(5).’’. (b) MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—Part D of title XVIII of the Social Security Act (42 U.S.C. 1395w–101) is amended by inserting after section 1860D–14 the following new section: ‘‘MEDICARE COVERAGE GAP DISCOUNT PROGRAM ‘‘SEC. 1860D–14A ø42 U.S.C. 1395w–114a¿. (a) ESTABLISHMENT.—The Secretary shall establish a Medicare coverage gap discount program (in this section referred to as the ‘program’) by not later than January 1, 2011. Under the program, the Secretary shall enter into agreements described in subsection (b) with manufacturers and provide for the performance of the duties described in subsection (c)(1). The Secretary shall establish a model agreement for use under the program by not later than 180 days after the date of the enactment of this section, in consultation with manufacturers, and allow for comment on such model agreement. øAs revised by section 1101(b)(2)(A) of HCERA¿ ‘‘(b) TERMS OF AGREEMENT.— ‘‘(1) IN GENERAL.— ‘‘(A) AGREEMENT.—An agreement under this section shall require the manufacturer to provide applicable beneficiaries access to discounted prices for applicable drugs of the manufacturer. ‘‘(B) PROVISION OF DISCOUNTED PRICES AT THE POINTOF-SALE.—Except as provided in subsection (c)(1)(A)(iii), such discounted prices shall be provided to the applicable beneficiary at the pharmacy or by the mail order service at the point-of-sale of an applicable drug. ‘‘(C) TIMING OF AGREEMENT.—øAs revised by section 1011(b)(2)(B) of HCERA¿ ‘‘(i) SPECIAL RULE FOR 2011.—In order for an agreement with a manufacturer to be in effect under this section with respect to the period beginning on January 1, 2011, and ending on December 31, 2011, the manufacturer shall enter into such agreement not later than not later than 30 days after the date of the establishment of a model agreement under subsection (a). ‘‘(ii) 2012 AND SUBSEQUENT YEARS.—In order for an agreement with a manufacturer to be in effect under this section with respect to plan year 2012 or a subsequent plan year, the manufacturer shall enter into such agreement (or such agreement shall be renewed under paragraph (4)(A)) not later than January 30 of the preceding year. ‘‘(2) PROVISION OF APPROPRIATE DATA.—Each manufacturer with an agreement in effect under this section shall collect and have available appropriate data, as determined by the Secretary, to ensure that it can demonstrate to the Secretary compliance with the requirements under the program. ‘‘(3) COMPLIANCE WITH REQUIREMENTS FOR ADMINISTRATION OF PROGRAM.—Each manufacturer with an agreement in effect under this section shall comply with requirements imposed by the Secretary or a third party with a contract under subsection (d)(3), as applicable, for purposes of administering the program, including any determination under clause (i) of subsection (c)(1)(A) or procedures established under such subsection (c)(1)(A). ‘‘(4) LENGTH OF AGREEMENT.— ‘‘(A) IN GENERAL.—An agreement under this section shall be effective for an initial period of not less than 18 months and shall be automatically renewed for a period of not less than 1 year unless terminated under subparagraph (B). ‘‘(B) TERMINATION.— ‘‘(i) BY THE SECRETARY.—The Secretary may provide for termination of an agreement under this section for a knowing and willful violation of the requirements of the agreement or other good cause shown. Such termination shall not be effective earlier than 30 days after the date of notice to the manufacturer of such termination. The Secretary shall provide, upon request, a manufacturer with a hearing concerning such a termination, and such hearing shall take place prior to the effective date of the termination with sufficient time for such effective date to be repealed if the Secretary determines appropriate. ‘‘(ii) BY A MANUFACTURER.—A manufacturer may terminate an agreement under this section for any reason. Any such termination shall be effective, with respect to a plan year— ‘‘(I) if the termination occurs before January 30 of a plan year, as of the day after the end of the plan year; and ‘‘(II) if the termination occurs on or after January 30 of a plan year, as of the day after the end of the succeeding plan year. ‘‘(iii) EFFECTIVENESS OF TERMINATION.—Any termination under this subparagraph shall not affect discounts for applicable drugs of the manufacturer that are due under the agreement before the effective date of its termination. ‘‘(iv) NOTICE TO THIRD PARTY.—The Secretary shall provide notice of such termination to a third party with a contract under subsection (d)(3) within not less than 30 days before the effective date of such termination. ‘‘(c) DUTIES DESCRIBED AND SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.— ‘‘(1) DUTIES DESCRIBED.—The duties described in this subsection are the following: ‘‘(A) ADMINISTRATION OF PROGRAM.—Administering the program, including— ‘‘(i) the determination of the amount of the discounted price of an applicable drug of a manufacturer; ‘‘(ii) except as provided in clause (iii), the establishment of procedures under which discounted prices are provided to applicable beneficiaries at pharmacies or by mail order service at the point-of-sale of an applicable drug; ‘‘(iii) in the case where, during the period beginning on January 1, 2011, and ending on December 31, 2011, it is not practicable to provide such discounted prices at the point-of-sale (as described in clause (ii)), the establishment of procedures to provide such discounted prices as soon as practicable after the pointof-sale; øAs revised by section 1011(b)(2)(C)(i) of HCERA¿ ‘‘(iv) the establishment of procedures to ensure that, not later than the applicable number of calendar days after the dispensing of an applicable drug by a pharmacy or mail order service, the pharmacy or mail order service is reimbursed for an amount equal to the difference between— ‘‘(I) the negotiated price of the applicable drug; and ‘‘(II) the discounted price of the applicable drug; ‘‘(v) the establishment of procedures to ensure that the discounted price for an applicable drug under this section is applied before any coverage or financial assistance under other health benefit plans or programs that provide coverage or financial assistance for the purchase or provision of prescription drug coverage on behalf of applicable beneficiaries as the Secretary may specify; ‘‘(vi) the establishment of procedures to implement the special rule for supplemental benefits under paragraph (2); and ‘‘(vii) providing a reasonable dispute resolution mechanism to resolve disagreements between manufacturers, applicable beneficiaries, and the third party with a contract under subsection (d)(3). ‘‘(B) MONITORING COMPLIANCE.— ‘‘(i) IN GENERAL.—The Secretary shall monitor compliance by a manufacturer with the terms of an agreement under this section. ‘‘(ii) NOTIFICATION.—If a third party with a contract under subsection (d)(3) determines that the manufacturer is not in compliance with such agreement, the third party shall notify the Secretary of such non-compliance for appropriate enforcement under subsection (e). ‘‘(C) COLLECTION OF DATA FROM PRESCRIPTION DRUG PLANS AND MA–PD PLANS.—The Secretary may collect appropriate data from prescription drug plans and MA–PD plans in a timeframe that allows for discounted prices to be provided for applicable drugs under this section. ‘‘(2) SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.—For plan year 2011 and each subsequent plan year, in the case where an applicable beneficiary has supplemental benefits with respect to applicable drugs under the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in, the applicable beneficiary shall not be provided a discounted price for an applicable drug under this section until after such supplemental benefits have been applied with respect to the applicable drug. øAs revised by section 1011(b)(2)(C)(ii) of HCERA¿ ‘‘(d) ADMINISTRATION.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall provide for the implementation of this section, including the performance of the duties described in subsection (c)(1). ‘‘(2) LIMITATION.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), in providing for such implementation, the Secretary shall not receive or distribute any funds of a manufacturer under the program. ‘‘(B) EXCEPTION.—The limitation under subparagraph (A) shall not apply to the Secretary with respect to drugs dispensed during the period beginning on January 1, 2011, and ending on December 31, 2011, but only if the Secretary determines that the exception to such limitation under this subparagraph is necessary in order for the Secretary to begin implementation of this section and provide applicable beneficiaries timely access to discounted prices during such period. øAs revised by section 1011(b)(2)(D) of HCERA¿ ‘‘(3) CONTRACT WITH THIRD PARTIES.—The Secretary shall enter into a contract with 1 or more third parties to administer the requirements established by the Secretary in order to carry out this section. At a minimum, the contract with a third party under the preceding sentence shall require that the third party— ‘‘(A) receive and transmit information between the Secretary, manufacturers, and other individuals or entities the Secretary determines appropriate; ‘‘(B) receive, distribute, or facilitate the distribution of funds of manufacturers to appropriate individuals or entities in order to meet the obligations of manufacturers under agreements under this section; ‘‘(C) provide adequate and timely information to manufacturers, consistent with the agreement with the manufacturer under this section, as necessary for the manufacturer to fulfill its obligations under this section; and ‘‘(D) permit manufacturers to conduct periodic audits, directly or through contracts, of the data and information compliance for appropriate enforcement under subsection (e). ‘‘(C) COLLECTION OF DATA FROM PRESCRIPTION DRUG PLANS AND MA–PD PLANS.—The Secretary may collect appropriate data from prescription drug plans and MA–PD plans in a timeframe that allows for discounted prices to be provided for applicable drugs under this section. ‘‘(2) SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.—For plan year 2011 and each subsequent plan year, in the case where an applicable beneficiary has supplemental benefits with respect to applicable drugs under the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in, the applicable beneficiary shall not be provided a discounted price for an applicable drug under this section until after such supplemental benefits have been applied with respect to the applicable drug. øAs revised by section 1011(b)(2)(C)(ii) of HCERA¿ ‘‘(d) ADMINISTRATION.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall provide for the implementation of this section, including the performance of the duties described in subsection (c)(1). ‘‘(2) LIMITATION.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), in providing for such implementation, the Secretary shall not receive or distribute any funds of a manufacturer under the program. ‘‘(B) EXCEPTION.—The limitation under subparagraph (A) shall not apply to the Secretary with respect to drugs dispensed during the period beginning on January 1, 2011, and ending on December 31, 2011, but only if the Secretary determines that the exception to such limitation under this subparagraph is necessary in order for the Secretary to begin implementation of this section and provide applicable beneficiaries timely access to discounted prices during such period. øAs revised by section 1011(b)(2)(D) of HCERA¿ ‘‘(3) CONTRACT WITH THIRD PARTIES.—The Secretary shall enter into a contract with 1 or more third parties to administer the requirements established by the Secretary in order to carry out this section. At a minimum, the contract with a third party under the preceding sentence shall require that the third party— ‘‘(A) receive and transmit information between the Secretary, manufacturers, and other individuals or entities the Secretary determines appropriate; ‘‘(B) receive, distribute, or facilitate the distribution of funds of manufacturers to appropriate individuals or entities in order to meet the obligations of manufacturers under agreements under this section; ‘‘(C) provide adequate and timely information to manufacturers, consistent with the agreement with the manufacturer under this section, as necessary for the manufacturer to fulfill its obligations under this section; and ‘‘(D) permit manufacturers to conduct periodic audits, directly or through contracts, of the data and information compliance for appropriate enforcement under subsection (e). ‘‘(C) COLLECTION OF DATA FROM PRESCRIPTION DRUG PLANS AND MA–PD PLANS.—The Secretary may collect appropriate data from prescription drug plans and MA–PD plans in a timeframe that allows for discounted prices to be provided for applicable drugs under this section. ‘‘(2) SPECIAL RULE FOR SUPPLEMENTAL BENEFITS.—For plan year 2011 and each subsequent plan year, in the case where an applicable beneficiary has supplemental benefits with respect to applicable drugs under the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in, the applicable beneficiary shall not be provided a discounted price for an applicable drug under this section until after such supplemental benefits have been applied with respect to the applicable drug. øAs revised by section 1011(b)(2)(C)(ii) of HCERA¿ ‘‘(d) ADMINISTRATION.— ‘‘(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall provide for the implementation of this section, including the performance of the duties described in subsection (c)(1). ‘‘(2) LIMITATION.— ‘‘(A) IN GENERAL.—Subject to subparagraph (B), in providing for such implementation, the Secretary shall not receive or distribute any funds of a manufacturer under the program. ‘‘(B) EXCEPTION.—The limitation under subparagraph (A) shall not apply to the Secretary with respect to drugs dispensed during the period beginning on January 1, 2011, and ending on December 31, 2011, but only if the Secretary determines that the exception to such limitation under this subparagraph is necessary in order for the Secretary to begin implementation of this section and provide applicable beneficiaries timely access to discounted prices during such period. øAs revised by section 1011(b)(2)(D) of HCERA¿ ‘‘(3) CONTRACT WITH THIRD PARTIES.—The Secretary shall enter into a contract with 1 or more third parties to administer the requirements established by the Secretary in order to carry out this section. At a minimum, the contract with a third party under the preceding sentence shall require that the third party— ‘‘(A) receive and transmit information between the Secretary, manufacturers, and other individuals or entities the Secretary determines appropriate; ‘‘(B) receive, distribute, or facilitate the distribution of funds of manufacturers to appropriate individuals or entities in order to meet the obligations of manufacturers under agreements under this section; ‘‘(C) provide adequate and timely information to manufacturers, consistent with the agreement with the manufacturer under this section, as necessary for the manufacturer to fulfill its obligations under this section; and ‘‘(D) permit manufacturers to conduct periodic audits, directly or through contracts, of the data and information used by the third party to determine discounts for applicable drugs of the manufacturer under the program. ‘‘(4) PERFORMANCE REQUIREMENTS.—The Secretary shall establish performance requirements for a third party with a contract under paragraph (3) and safeguards to protect the independence and integrity of the activities carried out by the third party under the program under this section. ‘‘(5) IMPLEMENTATION.—The Secretary may implement the program under this section by program instruction or otherwise. ‘‘(6) ADMINISTRATION.—Chapter 35 of title 44, United States Code, shall not apply to the program under this section. ‘‘(e) ENFORCEMENT.— ‘‘(1) AUDITS.—Each manufacturer with an agreement in effect under this section shall be subject to periodic audit by the Secretary. ‘‘(2) CIVIL MONEY PENALTY.— ‘‘(A) IN GENERAL.—The Secretary shall impose a civil money penalty on a manufacturer that fails to provide applicable beneficiaries discounts for applicable drugs of the manufacturer in accordance with such agreement for each such failure in an amount the Secretary determines is commensurate with the sum of— ‘‘(i) the amount that the manufacturer would have paid with respect to such discounts under the agreement, which will then be used to pay the discounts which the manufacturer had failed to provide; and ‘‘(ii) 25 percent of such amount. ‘‘(B) APPLICATION.—The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under this paragraph in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). ‘‘(f) CLARIFICATION REGARDING AVAILABILITY OF OTHER COVERED PART D DRUGS.—Nothing in this section shall prevent an applicable beneficiary from purchasing a covered part D drug that is not an applicable drug (including a generic drug or a drug that is not on the formulary of the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in). ‘‘(g) DEFINITIONS.—In this section: ‘‘(1) APPLICABLE BENEFICIARY.—The term ‘applicable beneficiary’ means an individual who, on the date of dispensing a covered part D drug—øAs revised by section 1101(b)(2)(E) of HCERA¿ ‘‘(A) is enrolled in a prescription drug plan or an MA– PD plan; ‘‘(B) is not enrolled in a qualified retiree prescription drug plan; ‘‘(C) is not entitled to an income-related subsidy under section 1860D–14(a); and øprevious subparagraph (D) stricken by section 1101(b)(2)(E) of HCERA¿ ‘‘(D) who—‘‘(i) has reached or exceeded the initial coverage limit under section 1860D–2(b)(3) during the year; and ‘‘(ii) has not incurred costs for covered part D drugs in the year equal to the annual out-of-pocket threshold specified in section 1860D–2(b)(4)(B). ‘‘(2) APPLICABLE DRUG.—The term ‘applicable drug’ means, with respect to an applicable beneficiary, a covered part D drug— ‘‘(A) approved under a new drug application under section 505(b) of the Federal Food, Drug, and Cosmetic Act or, in the case of a biologic product, licensed under section 351 of the Public Health Service Act (other than a product licensed under subsection (k) of such section 351); and ‘‘(B)(i) if the PDP sponsor of the prescription drug plan or the MA organization offering the MA–PD plan uses a formulary, which is on the formulary of the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in; ‘‘(ii) if the PDP sponsor of the prescription drug plan or the MA organization offering the MA–PD plan does not use a formulary, for which benefits are available under the prescription drug plan or MA–PD plan that the applicable beneficiary is enrolled in; or ‘‘(iii) is provided through an exception or appeal. ‘‘(3) APPLICABLE NUMBER OF CALENDAR DAYS.—The term ‘applicable number of calendar days’ means— ‘‘(A) with respect to claims for reimbursement submitted electronically, 14 days; and ‘‘(B) with respect to claims for reimbursement submitted otherwise, 30 days. ‘‘(4) DISCOUNTED PRICE.— ‘‘(A) IN GENERAL.—The term ‘discounted price’ means 50 percent of the negotiated price of the applicable drug of a manufacturer. ‘‘(B) CLARIFICATION.—Nothing in this section shall be construed as affecting the responsibility of an applicable beneficiary for payment of a dispensing fee for an applicable drug. ‘‘(C) SPECIAL CASE FOR CERTAIN CLAIMS.—In the case where the entire amount of the negotiated price of an individual claim for an applicable drug with respect to an applicable beneficiary does not fall at or above the initial coverage limit under section 1860D–2(b)(3) and below the annual out-of-pocket threshold specified in section 1860D– 2(b)(4)(B) for the year, the manufacturer of the applicable drug shall provide the discounted price under this section on only the portion of the negotiated price of the applicable drug that falls at or above such initial coverage limit and below such annual out-of-pocket threshold. ‘‘(5) MANUFACTURER.—The term ‘manufacturer’ means any entity which is engaged in the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis. Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law. ‘‘(6) NEGOTIATED PRICE.—The term ‘negotiated price’ has the meaning given such term in section 423.100 of title 42, Code of Federal Regulations (as in effect on the date of enactment of this section), except that such negotiated price shall not include any dispensing fee for the applicable drug. ‘‘(7) QUALIFIED RETIREE PRESCRIPTION DRUG PLAN.—The term ‘qualified retiree prescription drug plan’ has the meaning given such term in section 1860D–22(a)(2).’’. (c) INCLUSION IN INCURRED COSTS.— (1) IN GENERAL.—Section 1860D–2(b)(4) of the Social Security Act (42 U.S.C. 1395w–102(b)(4)) is amended— (A) in subparagraph (C), in the matter preceding clause (i), by striking ‘‘In applying’’ and inserting ‘‘Except as provided in subparagraph (E), in applying’’; and (B) by adding at the end the following new subparagraph: ‘‘(E) INCLUSION OF COSTS OF APPLICABLE DRUGS UNDER MEDICARE COVERAGE GAP DISCOUNT PROGRAM.—In applying subparagraph (A), incurred costs shall include the negotiated price (as defined in paragraph (6) of section 1860D– 14A(g)) of an applicable drug (as defined in paragraph (2) of such section) of a manufacturer that is furnished to an applicable beneficiary (as defined in paragraph (1) of such section) under the Medicare coverage gap discount program under section 1860D–14A, regardless of whether part of such costs were paid by a manufacturer under such program, except that incurred costs shall not include the portion of the negotiated price that represents the reduction in coinsurance resulting from the application of paragraph (2)(D). øAs revised by section 1101(b)(3)(E) of HCERA¿’’. (2) EFFECTIVE DATE.—The amendments made by this subsection shall apply to costs incurred on or after July 1, 2010. øSection 1101(b)(3) of HCERA amended section 1860D–2(b)(2) of the SSA to add subparagraphs (C) and (D) that provide coverage for generic drugs and applicable drugs in the coverage gap; and section 1101(b)(4) of HCERA amends section 1860D–22(a)(2)(A) in relation to not taking into account value of discounts or coverage in gap¿ øSection 1101(d) of HCERA amended section 1860D– 2(b)(4)(B)(i) and (7) of SSA to reduce growth rate of out-of-pocket cost threshold¿ (d) CONFORMING AMENDMENT PERMITTING PRESCRIPTION DRUG DISCOUNTS.— (1) IN GENERAL.—Section 1128B(b)(3) of the Social Security Act (42 U.S.C. 1320a–7b(b)(3)) is amended— (A) by striking ‘‘and’’ at the end of subparagraph (G); (B) in the subparagraph (H) added by section 237(d) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2213)—(i) by moving such subparagraph 2 ems to the left; and (ii) by striking the period at the end and inserting a semicolon; (C) in the subparagraph (H) added by section 431(a) of such Act (117 Stat. 2287)— (i) by redesignating such subparagraph as subparagraph (I); (ii) by moving such subparagraph 2 ems to the left; and (iii) by striking the period at the end and inserting ‘‘; and’’; and (D) by adding at the end the following new subparagraph: ‘‘(J) a discount in the price of an applicable drug (as defined in paragraph (2) of section 1860D–14A(g)) of a manufacturer that is furnished to an applicable beneficiary (as defined in paragraph (1) of such section) under the Medicare coverage gap discount program under section 1860D–14A.’’. (2) CONFORMING AMENDMENT TO DEFINITION OF BEST PRICE UNDER MEDICAID.—Section 1927(c)(1)(C)(i)(VI) of the Social Security Act (42 U.S.C. 1396r–8(c)(1)(C)(i)(VI)) is amended by inserting ‘‘, or any discounts provided by manufacturers under the Medicare coverage gap discount program under section 1860D–14A’’ before the period at the end. (3) EFFECTIVE DATE.—The amendments made by this subsection shall apply to drugs dispensed on or after July 1, 2010.
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