,i  #aad? ,,congress  #a/ ,session  ,h4 
,r4 #bbih  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,may #ac1 #bjae ,mr4  
,bilirakis 7= himself1 ,mr4 ,b5 ,ray    
,lujn ( ,new ,mexico1 & ,mr4 ,long7     
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 =     
programs to prev5t prescription drug    
abuse "u p>ts ,c & ,d ( ! ,m$ic>e       
program4  #a4 ,%ort title ,?is ,act may 
be cit$ z ! ,m$ic>e ,pati5t ,safety &   
,drug ,abuse ,prev5tion ,act4  #b4      
,programs to prev5t prescription drug   
abuse "u ,m$ic>e p>ts ,c & ,d  7a7 ,drug
 managem5t program = at-,risk           
b5efici>ies  7#a7 ,9 g5]al ,section     
#ahfj;,d-#d7;c7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #aciew-#aj7;c77 is  

am5d$ by add+ at ! end ! foll[+3  7#e7  
,drug managem5t program = at-risk       
b5efici>ies  7,a7 ,au?ority to e/abli%  
,a ,,pdp sponsor may e/abli% a drug     
managem5t program = at-risk b5efici>ies 
"u :i*1 subject to subp>agraph 7,b71 !  
,,pdp sponsor may1 9 ! case ( an at-risk
 b5efici>y = prescription drug abuse :o 
is an enrollee 9 a prescription drug    
plan ( su* ,,pdp sponsor1 limit su*     
b5efici>y's access to cov]age =         
frequ5tly abus$ drugs "u su* plan to    
frequ5tly abus$ drugs t are prescrib$ = 
su* b5efici>y by a prescrib] select$ "u 
subp>agraph 7,d71 & disp5s$ = su*       
b5efici>y by a ph>macy select$ "u su*   
subp>agraph4  7,b7 ,requirem5t = notices
  7i7 ,9 g5]al ,a ,,pdp sponsor may n   
limit ! access ( an at-risk b5efici>y = 
prescription drug abuse to cov]age =    
frequ5tly abus$ drugs "u a prescription 
drug plan until su* sponsor--  7,i7     
provides to ! b5efici>y an initial      
notice describ$ 9 clause 7ii7 & a second
 notice describ$ 9 clause 7iii72 &      

7,,ii7 v]ifies ) ! provid]s ( !         
b5efici>y t ! b5efici>y is an at-risk   
b5efici>y = prescription drug abuse4    
7ii7 ,initial notice ,an initial notice 
describ$ 9 ?is clause is a notice t     
provides to ! b5efici>y-- 7,i7 notice t 
! ,,pdp sponsor has id5tifi$ ! b5efici>y
 z pot5tially be+ an at-risk b5efici>y =
 prescription drug abuse2  7,,ii7       
in=mation describ+ all ,/ate & ,f$]al   
public heal? res\rces t are design$ to  
address prescription drug abuse to :i* !
 b5efici>y has access1 includ+ m5tal    
heal? s]vices & o!r c\nsel+ s]vices2    
7,,iii7 notice (1 & in=mation ab\t1 ! "r
 ( ! b5efici>y to appeal su*            
id5tification "u subsection 7h7 & !     
option ( an automatic escalation to     
ext]nal review2  7,,iv7 a reque/ = !    
b5efici>y to submit to ! ,,pdp sponsor  
pref]5ces = :i* prescrib]s & ph>macies !
 b5efici>y w\ld pref] ! ,,pdp sponsor to
 select "u subp>agraph 7,d7 9 ! case t !
 b5efici>y is id5tifi$ z an at-risk     
b5efici>y = prescription drug abuse z   

describ$ 9 clause 7iii77,i72  7,v7 an   
explanation ( ! mean+ & consequ5ces ( ! 
id5tification ( ! b5efici>y z pot5tially
 be+ an at-risk b5efici>y = prescription
 drug abuse1 includ+ an explanation ( ! 
drug managem5t program e/abli%$ by !    
,,pdp sponsor pursuant to subp>agraph   
7,a72  7,,vi7 cle> in/ructions t expla9 
h[ ! b5efici>y c contact ! ,,pdp sponsor
 9 ord] to submit to ! ,,pdp sponsor !  
pref]5ces describ$ 9 subclause 7,,iv7 & 
any o!r communications relat+ to ! drug 
managem5t program = at-risk b5efici>ies 
e/abli%$ by ! ,,pdp sponsor2 &  7,,vii7 
contact in=mation = o!r organizations t 
c provide ! b5efici>y ) assi/ance reg>d+
 su* drug managem5t program 7simil> to !
 in=mation provid$ by ! ,secret>y 9 o!r 
/&>diz$ notices provid$ to "p ,d        
eligible individuals enroll$ 9          
prescription drug plans "u ?is "p74     
7iii7 ,second notice ,a second notice   
describ$ 9 ?is clause is a notice t     
provides to ! b5efici>y notice-- 7,i7 t 
! ,,pdp sponsor has id5tifi$ ! b5efici>y

 z an at-risk b5efici>y = prescription  
drug abuse2  7,,ii7 t su* b5efici>y is  
subject to ! requirem5ts ( ! drug       
managem5t program = at-risk b5efici>ies 
e/abli%$ by su* ,,pdp sponsor = su*     
plan2  7,,iii7 ( ! prescrib] & ph>macy  
select$ = su* individual "u subp>agraph 
7,d72  7,,iv7 (1 & in=mation ab\t1 !    
b5efici>y's "r to appeal su*            
id5tification "u subsection 7h7 & !     
option ( an automatic escalation to     
ext]nal review2  7,v7 t ! b5efici>y c1 9
 ! case t ! b5efici>y has n previ\sly   
submitt$ to ! ,,pdp sponsor pref]5ces = 
:i* prescrib]s & ph>macies ! b5efici>y  
w\ld pref] ! ,,pdp sponsor select "u    
subp>agraph 7,d71 submit su* pref]5ces  
to ! ,,pdp sponsor2 &  7,,vi7 t includes
 cle> in/ructions t expla9 h[ !         
b5efici>y c contact ! ,,pdp sponsor4    
7iv7 ,tim+ ( notices  7,i7 ,9 g5]al     
,subject to subclause 7,,ii71 a second  
notice describ$ 9 clause 7iii7 %all be  
provid$ to ! b5efici>y on a date t is n 
less ?an #fj days aft] an initial notice

 describ$ 9 clause 7ii7 is provid$ to ! 
b5efici>y4  7,,ii7 ,exception ,9 ! case 
t ! ,,pdp sponsor1 9 conjunction ) !    
,secret>y1 det]m9es t conc]ns id5tifi$  
?r\gh rulemak+ by ! ,secret>y reg>d+ !  
heal? or safety ( ! b5efici>y or reg>d+ 
significant drug div]sion activities    
require ! ,,pdp sponsor to provide a    
second notice describ$ 9 clause 7iii7 to
 ! b5efici>y on a date t is e>li] ?an ! 
date describ$ 9 subclause 7,,ii71 !     
,,pdp sponsor may provide su* second    
notice on su* e>li] date4  7,c7 ,at-risk
 b5efici>y = prescription drug abuse    
7i7 ,9 g5]al ,= purposes ( ?is p>agraph1
 ! t]m at-risk b5efici>y = prescription 
drug abuse means a "p ,d eligible       
individual :o is n an exempt$ individual
 describ$ 9 clause 7ii7 &--  7,i7 :o is 
id5tifi$ ?r\gh ! use ( cl9ical guidel9es
 develop$ by ! ,secret>y 9 consultation 
) ,,pdp sponsors & o!r /akehold]s       
describ$ 9 subsection 7f77#b77;,a72 or  
7,,ii7 ) respect to :om ! ,,pdp sponsor 
( a prescription drug plan1 ^u enroll+  

su* individual 9 su* plan1 receiv$      
notice f ! ,secret>y t su* individual 0 
id5tifi$ "u ?is p>agraph to be an       
at-risk b5efici>y = prescription drug   
abuse "u ! prescription drug plan 9 :i* 
su* individual 0 mo/ rec5tly previ\sly  
enroll$ & su* id5tification has n be5   
t]m9at$ "u subp>agraph 7,f74  7ii7      
,exempt$ individual describ$ ,an exempt$
 individual describ$ 9 ?is clause is an 
individual :o-- 7,i7 an individual :o   
receives hospice c>e "u ?is title2 or   
7,,ii7 an individual1 su* z an          
individual :o is a resid5t ( a long-t]m 
c>e facility1 :o ! ,secret>y elects to  
treat z an exempt$ individual = purposes
 ( clause 7i74  7,d7 ,selection (       
prescrib]s  7i7 ,9 g5]al ,) respect to  
ea* at-risk b5efici>y = prescription    
drug abuse enroll$ 9 a prescription drug
 plan (f]$ by su* sponsor1 a ,,pdp      
sponsor %all1 bas$ on ! pref]5ces       
submitt$ to ! ,,pdp sponsor by !        
b5efici>y pursuant to clauses 7ii77,,iv7
 & 7iii77,v7 ( subp>agraph 7,b71        

select--  7,i7 "o or m individuals :o   
are au?oriz$ to prescribe frequ5tly     
abus$ drugs 7ref]r$ to 9 ?is p>agraph z 
prescrib]s7 :o may write prescriptions =
 su* drugs = su* b5efici>y2 &  7,,ii7 "o
 or m ph>macies t may disp5se su* drugs 
to su* b5efici>y4  7ii7 ,reasonable     
access ,9 mak+ ! selection "u ?is       
subp>agraph1 a ,,pdp sponsor %all ensure
 t ! b5efici>y cont9ues to h reasonable 
access to drugs describ$ 9 subp>agraph  
7,g71 tak+ into acc\nt geographic       
location1 b5efici>y pref]5ce1 impact on 
co/-%>+1 & reasonable travel "t4  7iii7 
,b5efici>y pref]5ces  7,i7 ,9 g5]al ,if 
an at-risk b5efici>y = prescription drug
 abuse submits pref]5ces = :i* 9-network
 prescrib]s & ph>macies ! b5efici>y w\ld
 pref] ! ,,pdp sponsor select 9 response
 to a notice "u subp>agraph 7,b71 !     
,,pdp sponsor %all--  7aa7 review su*   
pref]5ces2  7bb7 select or *ange !      
selection ( a prescrib] or ph>macy = !  
b5efici>y bas$ on su* pref]5ces2 &  7cc7
 in=m ! b5efici>y ( su* selection or    

*ange ( selection4  7,,ii7 ,exception ,9
 ! case t ! ,,pdp sponsor det]m9es t a  
*ange to ! selection ( a prescrib] or   
ph>macy "u item 7bb7 by ! ,,pdp sponsor 
is contribut+ or w\ld contribute to     
prescription drug abuse or drug div]sion
 by ! b5efici>y1 ! ,,pdp sponsor may    
*ange ! selection ( a prescrib] or      
ph>macy = ! b5efici>y )\t reg>d to !    
pref]5ces ( ! b5efici>y describ$ 9      
subclause 7,i74  7iv7 ,confirmation     
,be=e select+ a prescrib] or ph>macy "u 
?is subp>agraph1 a ,,pdp sponsor mu/    
reque/ & receive confirmation f !       
prescrib] or ph>macy ackn[l$g+ & accept+
 t ! b5efici>y involv$ is 9 ! drug      
managem5t program = at-risk b5efici>ies4
  7,e7 ,t]m9ations & appeals ,!         
id5tification ( an individual z an      
at-risk b5efici>y = prescription drug   
abuse "u ?is p>agraph1 a cov]age        
det]m9ation made "u a drug managem5t    
program = at-risk b5efici>ies1 & !      
selection ( a prescrib] or ph>macy "u   
subp>agraph 7,d7 ) respect to su*       

individual %all be subject to           
reconsid]ation & appeal "u subsection   
7h7 & ! option ( an automatic escalation
 to ext]nal review to ! ext5t provid$ by
 ! ,secret>y4  7,f7 ,t]m9ation (        
id5tification  7i7 ,9 g5]al ,! ,secret>y
 %all develop /&>ds = ! t]m9ation (     
id5tification ( an individual z an      
at-risk b5efici>y = prescription drug   
abuse "u ?is p>agraph4 ,"u su* /&>ds su*
 id5tification %all t]m9ate z ( ! e>li] 
(-- 7,i7 ! date ! individual demon/rates
 t ! individual is no long] likely1 9 ! 
abs5ce ( ! re/rictions "u ?is p>agraph1 
to be an at-risk b5efici>y =            
prescription drug abuse describ$ 9      
subp>agraph 7,c77i72 or  7,,ii7 ! end ( 
su* maximum p]iod ( id5tification z !   
,secret>y may specify4  7ii7 ,rule (    
con/ruction ,no?+ 9 clause 7i7 %all be  
con/ru$ z prev5t+ a plan f id5tify+ an  
individual z an at-risk b5efici>y =     
prescription drug abuse "u subp>agraph  
7,c77i7 aft] su* t]m9ation on ! basis ( 
additional in=mation on drug use occurr+

 aft] ! date ( notice ( su* t]m9ation4  
7,g7 ,frequ5tly abus$ drug ,= purposes (
 ?is subsection1 ! t]m frequ5tly abus$  
drug means a drug t is a controll$      
sub/ance t ! ,secret>y det]m9es to be   
frequ5tly abus$ or div]t$4  7,h7 ,data  
disclosure ,9 ! case ( an at-risk       
b5efici>y = prescription drug abuse ^:  
access to cov]age = frequ5tly abus$     
drugs "u a prescription drug plan has   
be5 limit$ by a ,,pdp sponsor "u ?is    
p>agraph1 su* ,,pdp sponsor %all        
disclose data1 includ+ any necess>y     
individually id5tifiable heal?          
in=mation1 9 a =m & mann] specifi$ by ! 
,secret>y1 ab\t ! decision to impose su*
 limitations & ! limitations impos$ by !
 sponsor "u ?is "p4  7,i7 ,education ,! 
,secret>y %all provide education to     
enrollees 9 prescription drug plans (   
,,pdp sponsors & provid]s reg>d+ ! drug 
managem5t program = at-risk b5efici>ies 
describ$ 9 ?is p>agraph1 includ+        
education-- 7i7 provid$ by m$ic>e       
adm9i/rative contractors ?r\gh ! improp]

 paym5t outrea* & education program     
describ$ 9 section #ahgd;,a7h72 &  7ii7 
?r\gh curr5t education ef=ts 7su* z     
,/ate heal? insurance assi/ance programs
 describ$ 9 subsection 7a77#a77;,a7 (   
section #aai ( ! ,m$ic>e ,improvem5ts = 
,pati5ts & ,provid]s ,act ( #bjjh 7#db  
,u4,s4,c4 #acie;b-#c note77 & mat]ials  
direct$ t[>d su* enrollees4  7,j7       
,application "u ,,ma-,,pd plans         
,pursuant to section                    
#ahfj;,d-#ba7;c77#a71 ! provisions ( ?is
 p>agraph apply "u "p ,d to ,,ma        
organizations (f]+ ,,ma-,,pd plans to   
,,ma eligible individuals 9 ! same mann]
 z su* provisions apply "u ?is "p to a  
,,pdp sponsor (f]+ a prescription drug  
plan to a "p ,d eligible individual4  4 
7#b7 ,in=mation = consum]s ,section     
#ahfj;,d-#d7;a77#a77;,b7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;a77#a77;,b77 is am5d$ by   
add+ at ! end ! foll[+3  7v7 ,! drug    
managem5t program = at-risk b5efici>ies 
"u subsection 7c77#e74  4  7b7          

,utilization managem5t programs ,section
 #ahfj;,d-#d7;c7 ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #aciew-#ajd7;c771 z 
am5d$ by subsection 7a77#a71 is fur!r   
am5d$-- 7#a7 9 p>agraph 7#a71 by ins]t+ 
aft] subp>agraph 7,d7 ! foll[+ new      
subp>agraph3  7,e7 ,a utilization       
managem5t tool to prev5t drug abuse 7z  
describ$ 9 p>agraph 7#f77;,a774  2 &    
7#b7 by add+ at ! end ! foll[+ new      
p>agraph3  7#f7 ,utilization managem5t  
tool to prev5t drug abuse  7,a7 ,9 g5]al
 ,a tool describ$ 9 ?is p>agraph is any 
( ! foll[+3 7i7 ,a utilization tool     
design$ to prev5t ! abuse ( frequ5tly   
abus$ drugs by individuals & to prev5t !
 div]sion ( su* drugs at ph>macies4     
7ii7 ,retrospective utilization review  
to id5tify-- 7,i7 individuals t receive 
frequ5tly abus$ drugs at a frequ5cy or 9
 am\nts t are n cl9ically appropriate2 &
  7,,ii7 provid]s ( s]vices or suppli]s 
t may facilitate ! abuse or div]sion (  
frequ5tly abus$ drugs by b5efici>ies4   
7iii7 ,consultation ) ! ,contractor     

describ$ 9 subp>agraph 7,b7 to v]ify if 
an individual enroll+ 9 a prescription  
drug plan (f]$ by a ,,pdp sponsor has   
be5 previ\sly id5tifi$ by ano!r ,,pdp   
sponsor z an individual describ$ 9      
clause 7ii77,i74  7,b7 ,report+ ,a ,,pdp
 sponsor (f]+ a prescription drug plan  
7& an ,,ma organization (f]+ an         
,,ma-,,pd plan7 9 a ,/ate %all submit to
 ! ,secret>y & ! ,m$ic>e drug integrity 
contractor ) :i* ! ,secret>y has ent]$  
into a contract "u section #ahic )      
respect to su* ,/ate a report1 on a     
mon?ly basis1 conta9+ in=mation on-- 7i7
 any provid] ( s]vices or suppli]       
describ$ 9 subp>agraph 7,a77ii77,,ii7 t 
is id5tifi$ by su* plan sponsor 7or     
organization7 dur+ ! #cj-;day p]iod be=e
 su* report is submitt$2 &  7ii7 ! "n & 
prescription records ( individuals      
describ$ 9 p>agraph 7#e77;,c74  4  7c7  
,exp&+ ,activities ( ,m$ic>e ,drug      
,integrity ,contractors 7,m,e,d,i,cs7   
7#a7 ,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 ,exp&+      
,activities ( ,m$ic>e ,drug ,integrity  
,contractors 7,m,e,d,i,cs7  7#a7 ,access
 to in=mation ,"u contracts ent]$ into  
"u ?is section ) ,m$ic>e drug integrity 
contractors1 ! ,secret>y %all au?orize  
su* contractors to directly accept      
prescription & necess>y m$ical records f
 entities su* z ph>macies1 prescription 
drug plans1 ,,ma-,,pd plans1 &          
physicians ) respect to an individual 9 
ord] = su* contractors to provide       
in=mation relevant to ! det]m9ation (   
:e!r su* individual is an at-risk       
b5efici>y = prescription drug abuse1 z  
def9$ 9 section                         
#ahfj;,d-#d7;c77#e77;,c74  7#b7         
,requirem5t = ackn[l$gm5t ( ref]rals ,if
 a ,,pdp sponsor or ,,ma organization   
ref]s in=mation to a contractor describ$
 9 p>agraph 7#a7 9 ord] = su* contractor
 to assi/ 9 ! det]m9ation describ$ 9 su*
 p>agraph1 ! contractor %all--  7,a7    
ackn[l$ge to ! sponsor or organization  

receipt ( ! ref]ral2 &  7,b7 9 ! case t 
any ,,pdp sponsor or ,,ma organization  
contacts ! contractor reque/+ to "k !   
det]m9ation by ! contractor ( :e!r or n 
an individual has be5 det]m9$ to be an  
individual describ$ su* p>agraph1 %all  
in=m su* sponsor or organization ( su*  
det]m9ation on a date t is n lat] ?an   
#ae days aft] ! date on :i* ! sponsor or
 organization contacts ! contractor4    
7#c7 ,mak+ data available to o!r        
entities  7,a7 ,9 g5]al ,= purposes (   
c>ry+ out ?is subsection1 subject to    
subp>agraph 7,b71 ! ,secret>y %all      
au?orize ,m,e,d,i,cs to respond to      
reque/s = in=mation f ,,pdp sponsors &  
,,ma organizations1 ,/ate prescription  
drug monitor+ programs1 & o!r entities  
delegat$ by su* sponsors or             
organizations us+ available programs &  
sy/ems 9 ! ef=t to prev5t fraud1 wa/e1 &
 abuse4  7,b7 ,,hipaa compliant         
in=mation only ,in=mation may only be   
disclos$ by a ,,m$ic "u subp>agraph 7,a7
 if ! disclosure ( su* in=mation is     

p]mitt$ "u ! ,f$]al regulations 7conc]n+
 ! privacy ( individually id5tifiable   
heal? in=mation7 promulgat$ "u section  
#bfd7;c7 ( ! ,heal? ,insurance          
,portability & ,acc\ntability ,act (    
#aiif 7#db ,u4,s4,c4 #acbj;d-#b note74  
4  7#b7 ,,oig /udy & report on          
effectiv5ess ( ,m,e,d,i,cs  7,a7 ,/udy  
,! ,inspector ,g5]al ( ! ,dep>tm5t (    
,heal? & ,human ,s]vices %all conduct a 
/udy on ! effectiv5ess ( ,m$ic>e drug   
integrity contractors 9 id5tify+        
combat+1 & prev5t+ fraud "u ! ,m$ic>e   
program1 includ+ "u ! au?ority provid$  
"u section #ahic7;j7 ( ! ,social        
,security ,act1 z add$ by p>agraph 7#a74
  7,b7 ,report ,n lat] ?an #a ye> aft] !
 date ( ! enactm5t ( ?is ,act1 !        
,inspector ,g5]al %all submit to        
,congress a report on ! /udy conduct$ "u
 subp>agraph 7,a74 ,su* report %all     
include su* recomm5dations = improvem5ts
 9 ! effectiv5ess ( su* contractors z ! 
,inspector ,g5]al det]m9es appropriate4 
7d7 ,treatm5t ( c]ta9 compla9ts =       

purposes ( quality or p]=mance assessm5t
 ,section #ahfj;,d-#db ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#aeb7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7d7 ,treatm5t (
 c]ta9 compla9ts = purposes ( quality or
 p]=mance assessm5t ,9 conduct+ a       
quality or p]=mance assessm5t ( a ,,pdp 
sponsor1 ! ,secret>y %all develop or    
utilize exi/+ scre5+ me?ods = review+ & 
consid]+ compla9ts t are receiv$ f      
enrollees 9 a prescription drug plan    
(f]$ by su* ,,pdp sponsor & t are       
compla9ts reg>d+ ! lack ( access by !   
individual to prescription drugs due to 
a drug managem5t program = at-risk      
b5efici>ies4  4  7e7 ,s5se ( congress   
reg>d+ use ( te*nology tools ,to combat 
fraud ,x is ! s5se ( ,congress t ,,ma   
organizations & ,,pdp sponsors %\ld     
consid] us+ e-prescrib+ & o!r heal?     
in=mation te*nology tools to support    
combat+ fraud "u ,,ma-,,pd plans &      
prescription drug plans "u p>ts ,c & ,d 
( ! ,m$ic>e program4  7f7 ,effective    

date  7#a7 ,9 g5]al ,! am5dm5ts made by 
?is section %all apply to prescription  
drug plans 7& ,,ma-,,pd plans7 = plan   
ye>s beg9n+ m ?an #a ye> aft] ! date ( !
 enactm5t ( ?is ,act4  7#b7 ,/akehold]  
meet+s prior to effective date  7,a7 ,9 
g5]al ,n lat] ?an ,janu>y #a1 #bjaf1 !  
,secret>y ( ,heal? & ,human ,s]vices    
%all conv5e /akehold]s1 includ+         
individuals entitl$ to b5efits "u "p ,a 
( title ,,xviii ( ! ,social ,security   
,act or enroll$ "u "p ,b ( su* title (  
su* ,act1 advocacy gr\ps repres5t+ su*  
individuals1 cl9icians1 plan sponsors1  
entities delegat$ by plan sponsors1 &   
bioph>maceutical manufactur]s = input   
reg>d+ ! topics describ$ 9 subp>agraph  
7,b74  7,b7 ,topics describ$ ,! topics  
describ$ 9 ?is subp>agraph are ! topics 
(--  7i7 ! impact on co/-%>+ & ensur+   
accessibility to prescription drugs =   
enrollees 9 prescription drug plans (   
,,pdp sponsors1 & enrollees 9 ,,ma-,,pd 
plans1 :o are at-risk b5efici>ies =     
prescription drug abuse 7z def9$ 9      

subp>agraph 7,c7 ( p>agraph 7#e7 (      
section #ahfj;,d-#d7;c7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;c7772  7ii7 ! use ( an     
exp$it$ appeals process "u :i* su* an   
enrollee may appeal an id5tification (  
su* enrollee z an at-risk b5efici>y =   
prescription drug abuse "u su* p>agraph 
7simil> to ! processes e/abli%$ "u !    
,m$ic>e ,advantage program "u "p ,c (   
title ,,xviii ( ! ,social ,security ,act
 t all[ an automatic escalation to      
ext]nal review ( claims submitt$ "u su* 
"p72  7iii7 ! types ( enrollees t %\ld  
be treat$ z exempt$ individuals1 z      
describ$ 9 subp>agraph 7,c77ii7 ( su*   
p>agraph2  7iv7 ! mann] 9 :i* t]ms &    
def9itions 9 su* p>agraph %\ld be       
appli$1 su* z ! use ( cl9ical           
appropriat5ess 9 det]m9+ :e!r an        
enrollee is an at-risk b5efici>y =      
prescription drug abuse z def9$ 9       
subp>agraph 7,c7 ( su* p>agraph2  7v7 ! 
in=mation to be includ$ 9 ! notices     
describ$ 9 subp>agraph 7,b7 ( su*       

p>agraph & ! /&>dization ( su* notices2 
&  7vi7 ) respect to a ,,pdp sponsor 7or
 ,m$ic>e ,advantage organization7 t     
e/abli%es a drug managem5t program =    
at-risk b5efici>ies "u su* p>agraph1 !  
responsibilities ( su* ,,pdp sponsor 7or
 organization7 ) respect to !           
implem5tation ( su* program4  7g7       
,rulemak+ ,! ,secret>y ( ,heal? & ,human
 ,s]vices %all promulgate regulations   
bas$ on ! input ga!r$ pursuant to       
subsection 7f77#b77;,a74