,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #fdj  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,m>* #d1 #bjai,mr4     
,k5n$y introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
require ph>macy-negotiat$ price         
concessions to be includ$ 9 negotiat$   
prices at ! po9t-(-sale "u "p ,d ( !    
,m$ic>e program1 & = o!r purposes4  #a4 
,%ort title ,?is ,act may be cit$ z !   
,phair ,pric+ ,act ( #bjai4  #b4        
,requir+ ph>macy-negotiat$ price        
concessions & ph>macy inc5tive paym5ts &
 adju/m5ts to be includ$ 9 negotiat$    
prices at ! po9t-(-sale "u "p ,d ( !    
,m$ic>e program ,section                
#ahfj;,d-#b7;d77#a77;,b7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#aciew-#ajb7;d77#a77;,b77 is am5d$--    
7#a7 by /rik+ prices4--,= purposes &    
ins]t+ 8prices4--  7i7 ,9 g5]al ,=      
purposes  2 &  7#b7 by add+ at ! end !  
foll[+ new clauses3  7ii7 ,prices       

negotiat$ ) ph>macy at po9t-(-sale  7,i7
 ,9 g5]al ,subject to subclause 7,,iii71
 = plan ye>s beg9n+ on or aft] ,janu>y  
#a1 #bjbj1 negotiat$ prices = cov]$ "p  
,d drugs describ$ 9 clause 7i7 provid$  
"u a prescription drug plan1 includ+ all
 cont+5t & noncont+5t concessions1      
adju/m5ts1 paym5ts1 & fees 7includ+     
disp5s+ fees7 negotiat$ ) ! ph>macy     
disp5s+ su* drug1 %all be provid$ at !  
po9t-(-sale ( su* drug4 ,su* negotiat$  
price %all n include any inc5tive       
paym5ts & adju/m5ts or any o!r cont+5t  
concessions1 adju/m5ts1 paym5ts1 or fees
 t increase ! am\nt ( su* negotiat$     
price4  7,,ii7 ,application ( ph>macy   
inc5tive paym5ts & adju/m5ts  7aa7 ,9   
g5]al ,= plan ye>s beg9n+ on or aft]    
,janu>y #a1 #bjbj1 a ,,pdp sponsor--    
7,,aa7 %all apply a sy/em "u :i*        
inc5tive paym5ts & adju/m5ts us+ only   
quality measures e/abli%$ by ! ,secret>y
 "u item 7bb7 are made to a ph>macy )   
respect to paym5t = cov]$ "p ,d drugs   
disp5s$ by su* ph>macy2 & 7,,bb7 may n  

apply any o!r inc5tive paym5ts &        
adju/m5ts ) respect to su* paym5t       
outside ( su* sy/em4  ,application ( su*
 sy/em may n result 9 a decrease 9      
reimbursem5t to su* ph>macy = su* drug  
aft] ! po9t-(-sale ( su* drug4  7bb7    
,/&>d ph>macy quality measures ,!       
,secret>y %all e/abli% /&>d quality     
measures t may be us$ 9 a sy/em describ$
 9 item 7aa74 ,su* measures %all be--   
7,,aa7 focus$ on improv+ pati5t heal?   
outcomes2 7,,bb7 /&>diz$ across ,,pdp   
sponsors2 7,,cc7 ph>macy-specific 9     
application2 7,,dd7 relevant to ! type (
 ph>macy conc]n$ 7su* z specialty       
ph>macies71 tak+ into acc\nt ! items &  
s]vices furni%$ by ! ph>macy & ! pati5t 
population s]v$ by ! ph>macy2 7,,ee7    
appli$ only :5 relevant to ! specific   
drug 7or drug class ( su* drug7 be+     
furni%$ by ! ph>macy or :5 relevant to  
managem5t ( ! condition = :i* su* drug  
has be5 prescrib$2 & 7,,ff7 bas$ on     
a*ievable & prov5 crit]ia measur+       
ph>macy p]=mance ov] :i* ! ph>macy has  

mean+ful control & ability to influ5ce4 
,9 e/abli%+ su* /&>ds1 ! ,secret>y %all 
consult ) /akehold]s1 includ+ ,,pdp     
sponsors & ,,ma organizations1 ph>macies
 across ph>macy practice types1 ph>macy 
b5efit manag]s1 pati5t advocacy         
organizations1 drug manufactur]s1       
appropriate /&>d-sett+ organizations1 & 
o!r entities det]m9$ appropriate by !   
,secret>y4  7,,iii7 ,no increase 9 co/  
%>+ ,subclause 7,i7 %all n apply 9 !    
case :]e application ( su* subclause    
w\ld increase ! am\nt ow$ by an         
individual 9 co/ %>+ above ! am\nt su*  
individual w\ld h ow$ 9 co/ %>+ )\t     
application ( su* subclause4  7,,iv7    
,discrepancies betwe5 negotiat$ prices &
 actual reimbursem5t ,9 ! case t !      
,secret>y det]m9es t ! negotiat$ price (
 a ,,pdp sponsor appli$ at ! po9t-(-sale
 ) respect to a cov]$ "p ,d drug = a ye>
 disp5s$ by a ph>macy 0 great] ?an !    
total reimbursem5t made to su* ph>macy =
 su* drug = su* ye>1 su* sponsor %all1 n
 lat] ?an #ij days aft] receiv+ notice (

 su* det]m9ation1 furni% to ! ph>macy t 
disp5s$ su* drug & to ! ,secret>y a     
writt5 explanation ( :y su* negotiat$   
price 0 great] ?an su* reimbursem5t4    
7,v7 ,specialty ph>macy ,= purposes (   
c>ry+ out ?is clause 7includ+ subclause 
7,,ii77bb77,,dd771 ! ,secret>y %all1 n  
lat] ?an ,decemb] #ca1 #bjai1 def9e !   
t]m specialty ph>macy 9 consultation )  
relevant /akehold]s4  7,,vi7 ,def9itions
 ,9 ?is clause3 7aa7 ,inc5tive paym5ts &
 adju/m5ts ,! t]m inc5tive paym5ts &    
adju/m5ts means1 ) respect to paym5t to 
a ph>macy by a ,,pdp sponsor = a cov]$  
"p ,d drug1 any prospective or          
retrospective price concessions1        
rebates1 disc\nts1 fees1 reconciliation 
adju/m5ts1 bonuses1 p]=mance paym5ts1   
inc5tives1 & any o!r adju/m5t to su*    
paym5t det]m9$ ?r\gh ! use ( a quality  
measure1 reg>dless ( :5 su* paym5ts &   
adju/m5ts are appli$4 ,su* t]m does n   
include any manufactur] rebates or      
concessions made ) respect to su* drug4 
7bb7 ,quality measure ,! t]m quality    

measure means p]=mance crit]ia us$ by a 
,,pdp sponsor 7includ+ an entity t      
contracts ) su* sponsor1 su* z a ph>macy
 b5efit manag]7 to det]m9e ! am\nt or   
applicability ( inc5tive paym5ts &      
adju/m5ts4  7cc7 ,,pdp sponsor ,! t]m   
,,pdp sponsor includes an ,,ma          
organization (f]+ an ,,ma-,,pd plan "u  
"p ,c & an entity t contracts ) su*     
sponsor or organization1 su* z a ph>macy
 b5efit manag]4  7iii7 ,reasonable      
reimbursem5t requirem5t ,9 no case may a
 negotiat$ price 7z describ$ 9 clause   
7ii77,i77 = a cov]$ "p ,d drug furni%$  
by a ph>macy dur+ a plan ye> beg9n+ on  
or aft] ,janu>y #a1 #bjbj1 be less ?an  
su* ph>macy's co/ ( pur*as+ & disp5s+   
su* drug & provid+ su* o!r s]vices      
associat$ ) furni%+ su* drug z may be   
specifi$ by ! ,secret>y4  7iv7 ,claim   
reimbursem5t disclosure requirem5ts ,)  
respect to paym5t made by a ,,pdp       
sponsor to a ph>macy = a cov]$ "p ,d    
drug furni%$ by su* ph>macy dur+ a plan 
ye> beg9n+ on or aft] ,janu>y #a1 #bjbj1

 su* sponsor %all promptly furni% all   
pric+ compon5ts includ+ ! ,network      
,reimbursem5t ,,id us$ to price ! claim1
 any fees1 ph>macy price concessions1   
disc\nts1 inc5tives or any o!r =ms (    
remun]ation t affect paym5t & pric+ ( ! 
claim z "p ( ! claim adjudication       
response at ! po9t-(-sale4 ,all         
a=em5tion$ items1 includ+ ,network      
,reimbursem5t ,,id1 fees1 ph>macy price 
concessions1 disc\nts1 inc5tives1 or any
 o!r =ms ( remun]ation t affect paym5t &
 pric+ ( ! claim %all ea* be id5tifi$ 9 
a pr$et]m9$ l9e item 9 ! remittance     
advice t is /&>d across ! indu/ry4 ,!   
,"p ,d sponsor %all include suitable    
claim-level detail on ! electronic      
remittance advice t accompanies ea*     
paym5t4 ,?is claim-level detail %all    
include1 9 an indu/ry /&>diz$ =mat1 all 
fields ne$$ to prop]ly id5tify ! claim1 
includ+ ! ,claim ,au?orization ,numb]1  
date ( s]vice1 date ( paym5t remittance1
 +r$i5t co/ reimburs$1 disp5s+ fee      
reimburs$1 paym5t am\nts includ+ !      

,network ,,id us$ to price ! claim1 !   
specific doll> am\nts & ! appropriate   
qualifi] codes = ea* paym5t adju/m5t    
includ+ fees1 ph>macy price concessions1
 or inc5tives4  7v7 ,violation process  
,a ,,pdp sponsor %all p>ticipate 9 any  
process e/abli%$ by ! ,secret>y =       
purposes ( det]m9+ :e!r su* sponsor has 
violat$ a provision ( clauses 7ii7 ?r\gh
 7iv74  4  #c4 ,ph>macy b5efit manag]   
provision ( in=mation  7a7 ,9 g5]al     
,section #aaej;,a7b77#b7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acbj;b-#bc7;b77#b77 is am5d$ by /rik+  
exclud+ & ins]t+ includ+4  7b7          
,effective date ,! am5dm5t made by      
subsection 7a7 %all apply ) respect to  
contract ye>s beg9n+ on or aft] ,janu>y 
#a1 #bjbj4