,i  #aae? ,,congress  #b;d ,session  ,h4
 ,r4 #eggc  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,may #aa1 #bjah,mr4   
,roskam 7= himself1 ,ms4 ,sewell (      
,alabama1 ,mr4 ,knight1 & ,ms4 ,s9ema7  
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 require       
,m$ic>e prescription drug plans to      
e/abli% drug managem5t programs =       
at-risk b5efici>ies1 require electronic 
prior au?orization = cov]$ "p ,d drugs1 
& to provide = o!r program integrity    
measures "u p>ts ,c & ,d ( ! ,m$ic>e    
program4  #a4 ,%ort title ,?is ,act may 
be cit$ z ! ,prev5t+ ,addiction =       
,susceptible ,s5iors ,act ( #bjah or !  
,,pass ,act ( #bjah 4  #b4 ,requir+     
prescription drug plan sponsors "u      

,m$ic>e to e/abli% drug managem5t       
programs = at-risk b5efici>ies ,section 
#ahfj;,d-#d7;c7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #aciew-#ajd7;c77 is 
am5d$--  7#a7 9 p>agraph 7#a71 by ins]t+
 aft] subp>agraph 7,e7 ! foll[+ new     
subp>agraph3  7,f7 ,) respect to plan   
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjba1 a drug managem5t program =       
at-risk b5efici>ies describ$ 9 p>agraph 
7#e74  2 &  7#b7 9 p>agraph 7#e77;,a71  
by ins]t+ 7& = plan ye>s beg9n+ on or   
aft] ,janu>y #a1 #bjba1 a ,,pdp sponsor 
%all7 aft] ,a ,,pdp sponsor may4  #c4   
,electronic prior au?orization = cov]$  
"p ,d drugs  7a7 ,inclusion 9 electronic
 prescription program ,section          
#ahfj;,d-#d7;e77#b7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;e77#b77 is am5d$ by add+ at
 ! end ! foll[+ new subp>agraph3  7,e7  
,electronic prior au?orization  7i7 ,9  
g5]al ,n lat] ?an ,janu>y #a1 #bjba1 !  
program %all provide = ! secure         
electronic transmittal (-- 7,i7 a prior 

au?orization reque/ f ! prescrib+ heal? 
c>e pr(essional = cov]age ( a cov]$ "p  
,d drug = a "p ,d eligible individual   
enroll$ 9 a "p ,d plan 7z def9$ 9       
section #ahfj;,d-#bc7;a77#e77 to ! ,,pdp
 sponsor or ,m$ic>e ,advantage          
organization (f]+ su* plan2 &  7,,ii7 a 
response1 9 accordance ) ?is            
subp>agraph1 f su* ,,pdp sponsor or     
,m$ic>e ,advantage organization1        
respectively1 to su* pr(essional4  7ii7 
,electronic transmission  7,i7          
,exclusions ,= purposes ( ?is           
subp>agraph1 a facsimile1 a propriet>y  
pay] portal t does n meet /&>ds specifi$
 by ! ,secret>y1 or an electronic =m    
%all n be treat$ z an electronic        
transmission describ$ 9 clause 7i74     
7,,ii7 ,/&>ds ,9 ord] to be treat$1 =   
purposes ( ?is subp>agraph1 z an        
electronic transmission describ$ 9      
clause 7i71 su* transmission %all comply
 ) te*nical /&>ds adopt$ by ! ,secret>y 
9 consultation ) ! ,national ,c\ncil =  
,prescription ,drug ,programs1 o!r /&>d 

sett+ organizations det]m9$ appropriate 
by ! ,secret>y1 & /akehold]s includ+    
,,pdp sponsors1 ,m$ic>e ,advantage      
organizations1 heal? c>e pr(essionals1 &
 heal? in=mation te*nology s(tw>e       
v5dors4  4  7b7 ,s5se ( ,congress reg>d+
 electronic prior au?orization ,x is !  
s5se ( ! ,congress t-- 7#a7 !re %\ld be 
increas$ use ( electronic prior         
au?orizations = cov]age ( cov]$ "p ,d   
drugs = "p ,d eligible individuals      
enroll$ 9 prescription drug plans "u "p 
,d ( title ,,xviii ( ! ,social ,security
 ,act & ,,ma-,,pd plans "u "p ,c ( su*  
title to r$uce access delays by resolv+ 
cov]age issues be=e prescriptions = su* 
drugs are transmitt$2 &  7#b7 great]    
priority %\ld be plac$ on increas+ !    
adoption ( use ( su* electronic prior   
au?orizations among prescrib]s ( su*    
drugs1 ph>macies1 ,,pdp sponsors1 &     
,m$ic>e ,advantage organizations4  #d4  
,program integrity transp>5cy measures  
"u ,m$ic>e p>ts ,c & ,d  7a7 ,9 g5]al   
,section #ahei ( ! ,social ,security    

,act 7#db ,u4,s4,c4 #aciew-#bh7 is am5d$
 by add+ at ! end ! foll[+ new          
subsection3  7i7 ,program integrity     
transp>5cy measures  7#a7 ,program      
integrity portal  7,a7 ,9 g5]al ,n lat] 
?an two ye>s aft] ! date ( ! enactm5t ( 
?is subsection1 ! ,secret>y %all1 aft]  
consultation ) /akehold]s1 e/abli% a    
secure ,int]net website portal 7or o!r  
successor te*nology7 t w\ld all[ a      
secure pa? = communication betwe5 !     
,secret>y1 ,,ma plans "u ?is "p1        
prescription drug plans "u "p ,d1 & an  
eligible entity ) a contract "u section 
#ahic 7su* z a ,m$ic>e drug integrity   
contractor or an entity responsible =   
c>ry+ out program integrity activities  
"u ?is "p & "p ,d7 = ! purpose ( enabl+ 
?r\gh su* portal 7or o!r successor      
te*nology7--  7i7 ! ref]ral by su* plans
 ( sub/antiat$ fraud1 wa/e1 & abuse =   
initiat+ or assi/+ inve/igations        
conduct$ by ! eligible entity2 &  7ii7  
data %>+ among su* ,,ma plans1          
prescription drug plans1 & ! ,secret>y4 

7,b7 ,requir$ uses ( portal ,! ,secret>y
 %all dissem9ate ! foll[+ in=mation to  
,,ma plans "u ?is "p & prescription drug
 plans "u "p ,d ?r\gh ! secure ,int]net 
website portal 7or o!r successor        
te*nology7 e/abli%$ "u subp>agraph 7,a73
  7i7 ,provid]s ( s]vices & suppli]s t h
 be5 ref]r$ pursuant to subp>agraph     
7,a77i7 dur+ ! previ\s #ab-mon? p]iod4  
7ii7 ,provid]s ( s]vices & suppli]s :o  
are ! subject ( an active exclusion "u  
section #aabh or :o are subject to a    
susp5sion ( paym5t "u ?is title pursuant
 to section #ahfb7o7 or o!rwise4  7iii7 
,provid]s ( s]vices & suppli]s :o are ! 
subject ( an active revocation (        
p>ticipation "u ?is title1 includ+ = n  
satisfy+ conditions ( p>ticipation4     
7iv7 ,9 ! case ( su* a plan t makes a   
ref]ral "u subp>agraph 7,a77i7 ?r\gh !  
portal 7or o!r successor te*nology7 )   
respect to activities ( sub/antiat$     
fraud1 wa/e1 or abuse ( a provid] (     
s]vices or suppli]1 if su* provid] or   
suppli] has be5 ! subject ( an          

adm9i/rative action "u ?is title or     
title ,,xi ) respect to simil>          
activities1 a notification to su* plan (
 su* action s tak54  7,c7 ,rulemak+ ,=  
purposes ( ?is p>agraph1 ! ,secret>y    
%all1 ?r\gh rulemak+1 specify :at       
con/itutes sub/antiat$ fraud1 wa/e1 &   
abuse1 us+ guidance su* z :at is provid$
 9 ! ,m$ic>e ,program ,integrity ,manual
 #d4g4a4 ,9 c>ry+ out ?is subsection1 a 
fraud hotl9e tip 7z def9$ by !          
,secret>y7 )\t fur!r evid5ce %all n be  
treat$ z suffici5t evid5ce = sub/antiat$
 fraud1 wa/e1 or abuse4  7,d7 ,,hipaa   
compliant in=mation only ,= purposes (  
?is subsection1 communications may only 
occur if ! communications are 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 (    
#aiif4  7#b7 ,qu>t]ly reports ,beg9n+   
two ye>s aft] ! date ( enactm5t ( ?is   
subsection1 ! ,secret>y %all make       

available to ,,ma plans "u ?is "p &     
prescription drug plans "u "p ,d 9 a    
timely mann] 7b no less frequ5tly ?an   
qu>t]ly7 & us+ in=mation submitt$ to an 
entity describ$ 9 p>agraph 7#a7 ?r\gh ! 
portal 7or o!r successor te*nology7     
describ$ 9 su* p>agraph or pursuant to  
section #ahic1 in=mation on fraud1 wa/e1
 & abuse s*emes & tr5ds 9 id5tify+      
suspici\s activity4 ,in=mation includ$ 9
 ea* su* report %all--  7,a7 include    
adm9i/rative actions1 p]t95t in=mation  
relat$ to opioid ov]prescrib+1 & o!r    
data det]m9$ appropriate by ! ,secret>y 
9 consultation ) /akehold]s2 &  7,b7 be 
anonymiz$ in=mation submitt$ by plans   
)\t id5tify+ ! s\rce ( su* in=mation4   
7#c7 ,cl>ification ,no?+ 9 ?is          
subsection %all be con/ru$ z preclud+ or
 o!rwise affect+ ref]rals describ$ 9    
subp>agraph 7,a7 t may o!rwise be made  
to law en=cem5t entities or to !        
,secret>y4  4  7b7 ,contract requirem5t 
,to communicate plan corrective actions 
aga9/ opioid ov]-,prescrib]s ,section   

#aheg7;e77#d77;,c7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#aciew-#bg7;e77#d77;,c77 is am5d$ by    
add+ at ! end ! foll[+ new p>agraph3    
7#e7 ,communicat+ plan corrective       
actions aga9/ opioids ov]-prescrib]s    
7,a7 ,9 g5]al ,beg9n+ ) plan ye>s beg9n+
 on or aft] ,janu>y #a1 #bjba1 a        
contract "u ?is section ) an ,,ma       
organization %all require ! organization
 to submit to ! ,secret>y1 ?r\gh !      
process e/abli%$ "u subp>agraph 7,b71   
in=mation on ! inve/igations & o!r      
actions tak5 by su* plans relat$ to     
provid]s ( s]vices :o prescribe a high  
volume ( opioids4  7,b7 ,process ,n lat]
 ?an ,janu>y #a1 #bjba1 ! ,secret>y     
%all1 9 consultation ) /akehold]s1      
e/abli% a process "u :i* ,,ma plans &   
prescription drug plans %all submit to !
 ,secret>y in=mation describ$ 9         
subp>agraph 7,a74  7,c7 ,regulations ,= 
purposes ( ?is p>agraph1 includ+ z      
appli$ "u section                       
#ahfj;,d-#ab7;b77#c77;,d71 ! ,secret>y  

%all1 pursuant to rulemak+--  7i7       
specify a def9ition = ! t]m high volume 
( opioids & a me?od = det]m9+ if a      
provid] ( s]vices prescribes su* a high 
volume2 &  7ii7 e/abli% ! process       
describ$ 9 subp>agraph 7,b7 & ! types ( 
in=mation t %all be submitt$ ?r\gh su*  
process4  4  7c7 ,ref]5ce "u "p ,d to   
program integrity transp>5cy measures   
,section #ahfj;,d-#d ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7m7 ,program   
integrity transp>5cy measures ,= program
 integrity transp>5cy measures appli$ ) 
respect to prescription drug plan & ,,ma
 plans1 see section #ahei7;i74  4  #e4  
,exp&+ eligibility = m$ication !rapy    
managem5t programs "u "p ,d  ,section   
#ahfj;,d-#d7;c77#b77;,a77ii7 ( ! ,social
 ,security ,act 7#db ,u4,s4,c4          
#aciew-#ajd7;c77#b77;,a77ii77 is am5d$--
  7#a7 by r$esignat+ subclauses 7,i7    
?r\gh 7,,iii7 z items 7aa7 ?r\gh 7cc71  
respectively1 & adju/+ ! m>g9s          

accord+ly2  7#b7 by /rik+ are "p ,d     
eligible individuals :o-- & ins]t+ are !
 foll[+3 7,i7 ,"p ,d eligible           
individuals :o--  2 &  7#c7 by add+ at !
 end ! foll[+ new subclause3  7,,ii7    
,beg9n+ ,janu>y #a1 #bjba1 at-risk      
b5efici>ies = prescription drug abuse 7z
 def9$ 9 p>agraph 7#e77;,c774  4  #f4   
,m$ic>e notifications to outli]         
prescrib]s ( opioids ,section           
#ahfj;,d-#d7;c77#d7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajd7;c77#d77 is am5d$ by add+ at
 ! end ! foll[+ new p>agraph3  7,d7     
,outli] prescrib] notification  7i7     
,notification ,beg9n+ n lat] ?an two    
ye>s aft] ! date ( ! enactm5t ( ?is     
subp>agraph1 ! ,secret>y %all1 9 ! case 
( a prescrib] id5tifi$ by ! ,secret>y "u
 clause 7ii7 to be an outli] prescrib] (
 opioids1 provide1 subject to clause    
7iv71 an annual notification to su*     
prescrib] t su* prescrib] has be5 s     
id5tifi$ & t includes res\rces on prop] 
prescrib+ me?ods & o!r in=mation        

specifi$ 9 accordance ) clause 7iii74   
7ii7 ,id5tification ( outli] prescrib]s 
( opioids  7,i7 ,9 g5]al ,! ,secret>y   
%all1 subject to subclause 7,,iii71 us+ 
! valid prescrib] ,national ,provid]    
,id5tifi]s includ$ pursuant to          
subp>agraph 7,a7 on claims = cov]$ "p ,d
 drugs = "p ,d eligible individuals     
enroll$ 9 prescription drug plans "u ?is
 "p or ,,ma-,,pd plans "u "p ,c & bas$  
on ! ?re%old e/abli%$ "u subclause      
7,,ii71 conduct an analysis to id5tify  
prescrib]s t are outli] opioid          
prescrib]s = a p]iod specifi$ by !      
,secret>y4  7,,ii7 ,e/abli%m5t ( ?re%old
 ,= purposes ( subclause 7,i7 & subject 
to subclause 7,,iii71 ! ,secret>y %all1 
aft] consultation ) /akehold]s1 e/abli% 
a ?re%old1 bas$ on prescrib] specialty &
 geographic area1 = id5tify+ :e!r a     
prescrib] 9 a specialty & geographic    
area is an outli] prescrib] ( opioids z 
comp>$ to o!r prescrib]s ( opioids )9   
su* specialty & area4  7,,iii7          
,exclusions ,! ,secret>y may exclude !  

foll[+ individuals & prescrib]s f !     
analysis "u ?is clause3  7aa7           
,individuals receiv+ hospice s]vices4   
7bb7 ,individuals ) a canc] diagnosis4  
7cc7 ,prescrib]s :o are ! subject ( an  
inve/igation by ! ,c5t]s = ,m$ic>e      
,m$icaid ,s]vices or ! ,(fice (         
,inspector ,g5]al ( ! ,dep>tm5t ( ,heal?
 & ,human ,s]vices4  7iii7 ,cont5ts (   
notification ,! ,secret>y %all1 bas$ on 
input f /akehold]s1 specify ! res\rces &
 o!r in=mation to be includ$ 9          
notifications provid$ "u clause 7i74    
7iv7 ,modifications & expansions  7,i7  
,frequ5cy ,beg9n+ #e ye>s aft] ! date ( 
! enactm5t ( ?is subp>agraph1 !         
,secret>y may *ange ! frequ5cy ( !      
notifications describ$ 9 clause 7i7 bas$
 on /akehold] input4  7,,ii7 ,expansion 
to o!r prescriptions ,! ,secret>y may   
exp& notifications "u ?is subp>agraph to
 include id5tifications & notifications 
) respect to concurr5t prescriptions (  
cov]$ ,"p ,d drugs us$ 9 comb9ation )   
opioids t are consid]$ to h adv]se side 

effects :5 s us$ 9 su* comb9ation1 z    
det]m9$ by ! ,secret>y4  7v7 ,opioids   
def9$ ,= purposes ( ?is subp>agraph1 !  
t]m opioids has su* mean+ z specifi$ by 
! ,secret>y ?r\gh program in/ruction or 
o!rwise4  4