§1860D-24. Coordination Requirements For Plans Providing Prescription Drug Coverage

Social Security Act

Title XVIII — Health Insurance for the Aged and Disabled

Part D — Voluntary Prescription Drug Benefit Program³⁹⁴

Subpart 3 — Application to Medicare Advantage Program and Treatment of Employer-Sponsored Programs and Other Prescription Drug Plans

(42 U.S.C. §1395w-134)

(a) Application of benefit coordination requirements to additional plans. -

(a)(1) In General. - The Secretary shall apply the coordination requirements established under section 1860D-23(a) to Rx plans described in subsection (b) in the same manner as such requirements apply to a State Pharmaceutical Assistance Program.

(a)(2) Application to treatment of certain out-of-pocket expenditures. - To the extent specified by the Secretary, the requirements referred to in paragraph (1) shall apply to procedures established under section 1860D-2(b)(4)(D).

(a)(3) User fees. -

(a)(3)(A) In General. - The Secretary may impose user fees for the transmittal of information necessary for benefit coordination under section 1860D-2(b)(4)(D) in a manner similar to the manner in which user fees are imposed under section 1842(h)(3)(B), except that the Secretary may retain a portion of such fees to defray the Secretary's costs in carrying out procedures under section 1860D-2(b)(4)(D).

(a)(3)(B) Application. - A user fee may not be imposed under subparagraph (A) with respect to a State Pharmaceutical Assistance Program.

(b) Rx plan. - An Rx plan described in this subsection is any of the following:

(b)(1) Medicaid programs. - A State plan under title XIX, including such a plan operating under a waiver under section 1115, if it meets the requirements of section 1860D-23(b)(2).

(b)(2) Group health plans. - An employer group health plan.

(b)(3) FEHBP. - The Federal employees health benefits plan under chapter 89 of title 5, United States Code.

(b)(4) Military coverage (including TRICARE). - Coverage under chapter 55 of title 10, United States Code.

(b)(5) Other prescription drug coverage. - Such other health benefit plans or programs that provide coverage or financial assistance for the purchase or provision of prescription drug coverage on behalf of part D eligible individuals as the Secretary may specify.

(c) Relation to other provisions. -

(c)(1) Use of cost management tools. - The requirements of this section shall not impair or prevent a PDP sponsor or MA organization from applying cost management tools (including differential payments) under all methods of operation.

(c)(2) No affect on treatment of certain out-of-pocket expenditures. - The requirements of this section shall not affect the Application of the procedures established under section 1860D-2(b)(4)(D).