42 U.S.C. § 1395w–152: Miscellaneous provisions

Summary

The Secretary can waive certain rules so people in U.S. territories (not the 50 states or DC) can get Part D drug coverage. The Secretary must apply the demonstration rules from section 402 of the Social Security Amendments of 1967 to Parts C and D, and use the Medicare Prescription Drug Account for Trust Fund references. For 2010 only, eligible people who passed the 2010 initial coverage limit by the last day of a calendar quarter must get a $250 payment from the Medicare Prescription Drug Account by the 15th day of the third month after that quarter, and each person can get only one such payment. When checking plan quality, the Secretary must use screening methods to review complaints from enrollees who say they could not get drugs because of drug management programs for at‑risk beneficiaries. Starting with plan years that begin January 1, 2028, the Secretary must publish reports at least every 2 years through 2034 and periodically after that. The reports must, where possible, show trends and comparisons about payments, fees, pharmacy participation, numbers, cost‑sharing, and dispensing volume for “essential retail pharmacies” versus other pharmacies and between PDP and MA‑PD networks. Essential retail pharmacy: a retail pharmacy that is not an affiliate and that has no other retail pharmacy within 10 miles in rural areas, 2 miles in suburban areas, or 1 mile in urban areas. Affiliate and pharmacy benefit manager: use the meanings from section 1395w–112(h)(7). Each plan year starting 2028 the Secretary must post a public list of essential retail pharmacies. PDP sponsors and MA organizations must give the Secretary lists of their affiliate pharmacies and, beginning with plan year 2027, report incentive payments and other fees to pharmacies. The Secretary can implement these rules by program instructions and the Paperwork Reduction Act does not apply. The Secretary must also publish an enforcement and oversight report no later than 2 years after February 3, 2026 and at least every 2 years after that, without revealing identifiable individual or entity information or trade secrets.

Title 42, §1395w–152

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Access to coverage in territories

The Secretary may waive such requirements of this part, including section 1395w–103(a)(1) of this title, insofar as the Secretary determines it is necessary to secure access to qualified prescription drug coverage for part D eligible individuals residing in a State (other than the 50 States and the District of Columbia).

(b)Application of demonstration authority

The provisions of section 402 of the Social Security Amendments of 1967 (Public Law 90–248) shall apply with respect to this part and part C in the same manner it applies with respect to parts A and B, except that any reference with respect to a Trust Fund in relation to an experiment or demonstration project relating to prescription drug coverage under this part shall be deemed a reference to the Medicare Prescription Drug Account within the Federal Supplementary Medical Insurance Trust Fund.

(c)Coverage gap rebate for 2010

(1)In general

In the case of an individual described in subparagraphs (A) through (D) of section 1395w–114a(g)(1) of this title who as of the last day of a calendar quarter in 2010 has incurred costs for covered part D drugs so that the individual has exceeded the initial coverage limit under section 1395w–102(b)(3) of this title for 2010, the Secretary shall provide for payment from the Medicare Prescription Drug Account of $250 to the individual by not later than the 15th day of the third month following the end of such quarter.

(2)Limitation

The Secretary shall provide only 1 payment under this subsection with respect to any individual.

(d)Treatment of certain complaints for purposes of quality or performance assessment

In conducting a quality or performance assessment of a PDP sponsor, the Secretary shall develop or utilize existing screening methods for reviewing and considering complaints that are received from enrollees in a prescription drug plan offered by such PDP sponsor and that are complaints regarding the lack of access by the individual to prescription drugs due to a drug management program for at-risk beneficiaries.

(e)Essential retail pharmacies

(1)In general

With respect to plan years beginning on or after January 1, 2028, the Secretary shall publish reports, at least once every 2 years until 2034, and periodically thereafter, that provide information, to the extent feasible, on—

(A)trends in ingredient cost reimbursement, dispensing fees, incentive payments and other fees paid by PDP sponsors offering prescription drug plans and MA organizations offering MA–PD plans under this part to essential retail pharmacies (as defined in paragraph (2)) with respect to the dispensing of covered part D drugs, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies;

(B)trends in amounts paid to PDP sponsors offering prescription drug plans and MA organizations offering MA–PD plans under this part by essential retail pharmacies with respect to the dispensing of covered part D drugs, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies;

(C)trends in essential retail pharmacy participation in pharmacy networks and preferred pharmacy networks for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part, including a comparison of such trends between essential retail pharmacies and pharmacies that are not essential retail pharmacies;

(D)trends in the number of essential retail pharmacies, including variation in such trends by geographic region or other factors;

(E)a comparison of cost-sharing for covered part D drugs dispensed by essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part and cost-sharing for covered part D drugs dispensed by other network pharmacies for such plans located in similar geographic areas that are not essential retail pharmacies;

(F)a comparison of the volume of covered part D drugs dispensed by essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors and MA–PD plans offered by MA organizations under this part and such volume of dispensing by network pharmacies for such plans located in similar geographic areas that are not essential retail pharmacies, including information on any patterns or trends in such comparison specific to certain types of covered part D drugs, such as generic drugs or drugs specified as specialty drugs by a PDP sponsor under a prescription drug plan or an MA organization under an MA–PD plan; and

(G)a comparison of the information described in subparagraphs (A) through (F) between essential retail pharmacies that are network pharmacies for prescription drug plans offered by PDP sponsors under this part and essential retail pharmacies that are network pharmacies for MA–PD plans offered by MA organizations under this part.

(2)Definition of essential retail pharmacy

In this subsection, the term “essential retail pharmacy” means, with respect to a plan year, a retail pharmacy that—

(A)is not a pharmacy that is an affiliate as defined in paragraph (4); and

(B)is located in—

(i)a rural area in which there is no other retail pharmacy within 10 miles, as determined by the Secretary;

(ii)a suburban area in which there is no other retail pharmacy within 2 miles, as determined by the Secretary; or

(iii)an urban area in which there is no other retail pharmacy within 1 mile, as determined by the Secretary.

(3)List of essential retail pharmacies

(A)Publication of list of essential retail pharmacies

For each plan year (beginning with plan year 2028), the Secretary shall publish, on a publicly available internet website of the Centers for Medicare & Medicaid Services, a list of retail pharmacies that meet the criteria described in subparagraphs (A) and (B) of paragraph (2) to be considered an essential retail pharmacy.

(B)Required submissions from PDP sponsors

For each plan year (beginning with plan year 2028), each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan shall submit to the Secretary, for the purposes of determining retail pharmacies that meet the criterion specified in subparagraph (A) of paragraph (2), a list of retail pharmacies that are affiliates of such sponsor or organization, or are affiliates of a pharmacy benefit manager acting on behalf of such sponsor or organization, at a time, and in a form and manner, specified by the Secretary.

(C)Reporting by PDP sponsors and MA organizations

For each plan year beginning with plan year 2027, each PDP sponsor offering a prescription drug plan and each MA organization offering an MA–PD plan under this part shall submit to the Secretary information on incentive payments and other fees paid by such sponsor or organization to pharmacies, insofar as any such payments or fees are not otherwise reported, at a time, and in a form and manner, specified by the Secretary.

(D)Implementation

Notwithstanding any other provision of law, the Secretary may implement this paragraph by program instruction or otherwise.

(E)Nonapplication of Paperwork Reduction Act

Chapter 35 of title 44 shall not apply to the implementation of this paragraph.

(4)Definition of affiliate; pharmacy benefit manager

In this subsection, the terms “affiliate” and “pharmacy benefit manager” have the meaning given those terms in section 1395w–112(h)(7) of this title.

(f)Biennial report on enforcement and oversight of pharmacy access requirements

(1)In general

Not later than 2 years after February 3, 2026, and at least once every 2 years thereafter, the Secretary shall publish a report on enforcement and oversight actions and activities undertaken by the Secretary with respect to the requirements under section 1395w–104(b)(1) of this title.

(2)Limitation

A report under paragraph (1) shall not disclose—

(A)identifiable information about individuals or entities unless such information is otherwise publicly available; or

(B)trade secrets with respect to any entities.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 402 of the Social Security

Amendments

of 1967, referred to in subsec. (b), is section 402 of Pub. L. 90–248, title IV, Jan. 2, 1968, 81 Stat. 930, which enacted section 1395b–1 of this title and amended section 1395ll of this title.

Amendments

2026—Subsec. (e). Pub. L. 119–75, § 6223(b), added subsec. (e). Subsec. (f). Pub. L. 119–75, § 6223(e), added subsec. (f). 2016—Subsec. (d). Pub. L. 114–198 added subsec. (d). 2010—Subsec. (c). Pub. L. 111–152 added subsec. (c).

Statutory Notes and Related Subsidiaries

Effective Date

of 2016 AmendmentAmendment by Pub. L. 114–198 applicable to prescription drug plans (and MA–PD plans) for plan years beginning on or after Jan. 1, 2019, see section 704(g)(1) of Pub. L. 114–198, set out as a note under section 1395w–101 of this title.

§1395w–152 Miscellaneous Provisions

Summary

Title 42, §1395w–152

Notes & Related Subsidiaries

Editorial Notes

References in Text

Amendments

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Citations & Metadata