,i #aac? ,,congress #a/ ,session ,h4 ,r4 #ccib ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,octob] #cj1 #bjac,mr4 ,bilirakis 7= himself & ,mr4 ,b5 ,ray ,lujn ( ,new ,mexico7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,en]gy & ,comm]ce1 & 9 addition to ! ,committee on ,ways & ,means1 = a p]iod to be subsequ5tly det]m9$ by ! ,speak]1 9 ea* case = consid]ation ( su* provisions z fall )9 ! jurisdiction ( ! committee conc]n$ ,a ,,bill ,to am5d title ,,xviii ( ! ,social ,security ,act to provide = a ,,pdp safety program to prev5t fraud & abuse 9 ! disp5s+ ( controll$ sub/ances "u "p ,d ( ! ,m$ic>e program1 & = o!r purposes4 #a4 ,%ort title2 table ( cont5ts 7a7 ,%ort title ,?is ,act may be cit$ z ! ,m$ic>e ,"p ,d ,pati5t ,safety & ,drug ,abuse ,prev5tion ,act ( #bjac4 7b7 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title2 table ( cont5ts4,sec4 #b4 ,e/abli%+ ,,pdp safety program to prev5t fraud & abuse 9 ,m$ic>e prescription drug plans4,sec4 #c4 ,"p ,d susp5sion ( claims paym5t4,sec4 #d4 ,improv+ activities ( ,m$ic>e ,drug ,integrity ,contractors 7,m,e,d,i,cs74,sec4 #e4 ,requir+ e-prescrib+ = cov]age ( cov]$ "p ,d controll$ sub/ances4 #b4 ,e/abli%+ ,,pdp safety program to prev5t fraud & abuse 9 ,m$ic>e prescription drug plans 7a7 ,,pdp safety program ,section #ahfj;,d-#d7;c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77 is am5d$-- 7#a7 9 p>agraph 7#a77;,d7-- 7,a7 by ins]t+ 1 design$ to aft] program2 & 7,b7 by ins]t+ 1 t includes ! proc$ures describ$ 9 p>agraph 7#d7 aft] wa/e2 & 7#b7 by add+ at ! end ! foll[+3 7#d7 ,safe ph>macy access program 7,a7 ,,pdp sponsor proc$ures ,a ,,pdp sponsor 7or an ,,ma organization (f]+ an ,,ma-,,pd plan7 %all h 9 place proc$ures design$-- 7i7 to id5tify an individual :o has obta9$ cov]age = a cov]$ "p ,d drug t is a frequ5tly abus$ s*$ule ,,ii1 ,,iii1 ,,iv1 or ,v controll$ sub/ance1 z det]m9$ 9 accordance ) utilization guidel9es e/abli%$ by ! ,secret>y & ! sponsor 7or ,,ma organization71 & to notify su* individuals t !y h be5 s id5tifi$2 7ii7 to contract ) ph>macies au?oriz$ to disp5se su* controll$ sub/ances to create a safe ph>macy network t meets ! crit]ia specifi$ 9 subp>agraph 7,c72 7iii7 tak+ into acc\nt ! location ( ! individual's resid5ce 7or resid5ces71 "w site1 mobility1 & o!r relevant factors1 to limit cov]age to s*$ule ,,ii1 ,,iii1 ,,iv1 or ,v controll$ sub/ances = "s or all classes ( cov]$ "p ,d drugs = an individual id5tifi$ "u clause 7i7 7or "u subp>agraph 7,b77 to drugs disp5s$ by "o or m ph>macies contract$ ) "u clause 7ii72 7iv7 to provide to ! ,secret>y ! "n1 & o!r in=mation t ! ,secret>y may require1 ( individuals s id5tifi$ & ( ! fact ( su* individual's dis5rollm5t 7if any7 f ! plan ( ! sponsor 7or ! ,,ma-,,pd plan (f]$ by ! ,,ma organization72 7v7 to provide = an appeals process :]eby an individual s id5tifi$ may appeal su* id5tification on ! basis t ! id5tification 0 n appropriate2 7vi7 to provide = a process :]eby an individual s id5tifi$ may petition = ! t]m9ation ( su* id5tification on ! basis t ! limitation on cov]age is no long] necess>y to prev5t fraud & abuse by ! individual2 & 7vii7 to provide t cov]age %all be provid$ = a s*$ule ,,ii1 ,,iii1 ,,iv1 or ,v controll$ sub/ance only if x prescrib$ 9 accordance ) an electronic prescrib+ program "u subsection 7e71 except 9 su* exceptional circum/ances z ! ,secret>y may p]mit4 7,b7 ,%>+ in=mation = subsequ5t plan enrollm5ts ,! ,secret>y %all %>e in=mation1 ) respect to ! id5tity ( an individual id5tifi$ "u subp>agraph 7,a77i7 :o dis5rolls f a plan "u subp>agraph 7,a77iv71 ) a ,,pdp sponsor 7or ,,ma organization7 t subsequ5tly enrolls su* individual "u ano!r plan 9 ord] t ! provisions ( subp>agraph 7,a77iii7 w\ld apply "u su* subsequ5t enrollm5t4 7,c7 ,safe ph>macy network crit]ia ,! crit]ia specifi$ 9 ?is subp>agraph = a safe ph>macy network are ! foll[+3 7i7 ,! ph>macies 9 ! network are able to prop]ly monitor ! usage ( s*$ule ,,ii1 ,,iii1 ,,iv1 & ,v controll$ sub/ances4 7ii7 ,su* ph>macies & network meet su* o!r drug safety crit]ia z ! ,secret>y or ! ,,pdp sponsor 7or ,,ma organization7 det]m9es to be appropriate1 su* z use ( a ,/ate prescription drug monitor+ program1 if su* a program is available 9 ! ,/ate4 4 7b7 ,dual eligibles ,section #ahfj;,d-#a7;b77#c77;,d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aja7;b77#c77;,d77 is am5d$ by ins]t+ 1 subject to su* limits z ! ,secret>y may e/abli% = individuals id5tifi$ pursuant to section #ahfj;,d-#d7;c77#d77;,a77i7 aft] ! ,secret>y4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply ) respect to plan ye>s beg9n+ aft] ! date t is #h mon?s aft] ! date ( ! enactm5t ( ?is ,act4 #c4 ,"p ,d susp5sion ( claims paym5t ,am5d #ahfj;,d-#ab7;b77#d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#aab7;b77#d77 is am5d$ by add+ at ! end ! foll[+ new subp>agraph3 7,h7 ,susp5sion ( paym5ts p5d+ inve/igation ( cr$ible allegations ( fraud by ph>macies 7i7 ,9 g5]al ,a ,,pdp sponsor may susp5d paym5ts & clean claim notifications to a ph>macy p5d+ an inve/igation ( a cr$ible allegation ( fraud 7z def9$ 9 clause 7ii77 aga9/ ! ph>macy1 unless ! ,secret>y det]m9es !re is a good cause n to susp5d paym5ts4 7ii7 ,cr$ible allegation ( fraud def9$ ,9 ?is subp>agraph1 ! t]m cr$ible allegation ( fraud includes-- 7,i7 a compla9t made on ! ,m$ic>e fraud hotl9e2 7,,ii7 detection ( pot5tial fraud ?r\gh ! analysis ( claims data2 7,,iii7 detection ( pot5tial fraud ?r\gh id5tification ( inappropriate disp5s+ ?r\gh audits1 civil false claims cases1 & law en=cem5t inve/igations2 & 7,,iv7 claims ref]r$ to ,m$ic>e drug integrity contractors 7,m,e,d,i,cs74 7iii7 ,rule ( con/ruction ,no?+ 9 ?is subp>agraph %all be con/ru$ z limit$ ! au?ority ( a ,,pdp sponsor to conduct po/-claim paym5t review4 4 #d4 ,improv+ activities ( ,m$ic>e ,drug ,integrity ,contractors 7,m,e,d,i,cs7 7a7 ,9 g5]al ,section #ahic ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7j7 ,improv+ activities ( ,m$ic>e ,drug ,integrity ,contractors 7,m,e,d,i,cs7 7#a7 ,access to ,9 g5]al ,"u contracts ent]$ into "u ?is section 7ea* 9 ?is subsection ref]r$ to z a ,,m$ic contract7 ) ,m$ic>e drug integrity contractors 7ea* 9 ?is subsection ref]r$ to z a ,,m$ic71 ! ,secret>y %all au?orize ,m,e,d,i,cs to directly obta9 prescription & m$ical records f entities su* z ph>macies1 ,,pdp & physicians4 7#b7 ,requirem5t = ackn[l$gm5t ( ref]rals ,if a ,,pdp sponsor ref]s in=mation to a ,,m$ic = inve/igation1 "u ! ,,m$ic contract ! ,,m$ic mu/ ackn[l$ge receipt ( ! ref]ral & mu/ report back to ! sponsor ! result ( ! ,,m$ic's inve/igation )9 #de days ( ! date ( ! ref]ral & %>e su* results ) appropriate ag5cies1 su* z law en=cem5t (ficials & ,/ate lic5s+ au?ority4 7#c7 ,uni=m annual report crit]ia ,9 ord] to assess ! p]=mance ( ,m,e,d,i,cs1 ! ,secret>y %all develop a uni=m report+ crit]ia = ! annual report+ ( ! results ( inve/igations by ,m,e,d,i,cs to ! ,secret>y & to ,congress4 ,ea* su* annual report %all include in=mation on ! numb] ( ref]rals = inve/igation made to a ,,m$ic1 ! av]age "t requir$ = inve/igation1 ! results ( ! inve/igation1 & ! numb] ( results t 7 ref]r$ to ! ,inspector ,g5]al ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices & to ,/ate lic5s+ (ficials = fur!r inve/igations4 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all take effect on ! date ( ! enactm5t ( ?is ,act & %all apply z quickly z possible to ,,m$ic contracts1 includ+ ,,m$ic contracts ent]$ into be=e su* date ( enactm5t4 #e4 ,requir+ e-prescrib+ = cov]age ( cov]$ "p ,d controll$ sub/ances 7a7 ,9 g5]al ,section #ahfj;,d-#d7;e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciew-#ajd7;e77 is am5d$ by add+ at ! end ! foll[+3 7#g7 ,requirem5t ( e-prescrib+ = controll$ sub/ances ,except 9 su* em]g5t circum/ances z ! ,secret>y may specify1 cov]age %all n be provid$ = a cov]$ "p ,d drug "u a prescription drug plan 7or "u an ,,ma-,,pd plan7 = a s*$ule ,,ii1 ,,iii1 ,,iv1 or ,v controll$ sub/ance unless ! prescription = ! drug has be5 transmitt$ electronically 9 accordance ) an electronic prescription drug program t meets ! requirem5ts ( p>agraph 7#b74 4 7b7 ,effective date ,! am5dm5t made by subsection 7a7 %all apply to cov]age ( drugs prescrib$ on or aft] ,janu>y #a1 #bjae4