,,ib ,union ,cal5d> ,no4 #gfg #aah? ,,congress #b;d ,session ,h4 ,r4 #dejg ,report ,no4 #aah-gdb1 ,"p ,i ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,july #aj1 #bjbc ,mr4 ,good ( ,virg9ia 7= himself & ,mr4 ,de,saulnier7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,education & ! ,work=ce1 & 9 addition to ! ,committees on ,en]gy & ,comm]ce1 & ,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$ ,novemb] #ah1 #bjbd ,report$ f ! ,committee on ,education & ! ,work=ce ) an am5dm5t ,/rike out all aft] ! enact+ clause & ins]t ! "p pr9t$ 9 italic ,novemb] #ah1 #bjbd ,ref]ral to ! ,committees on ,en]gy & ,comm]ce & ,ways & ,means ext5d$ = a p]iod end+ n lat] ?an ,decemb] #ai1 #bjbd ,decemb] #ai1 #bjbd ,additional sponsor3 ,mr4 ,norman ,decemb] #ai1 #bjbd ,committees on ,en]gy & ,comm]ce & ,ways & ,means dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be pr9t$ ,= text ( introduc$ bill1 see copy ( bill z introduc$ on ,july #aj1 #bjbc ,a ,,bill ,to am5d ! ,employee ,retirem5t ,income ,security ,act ( #aigd to promote transp>5cy 9 heal? cov]age & re=m ph>macy b5efit managem5t s]vices ) respect to gr\p heal? plans1 & = o!r purposes4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,transp>5cy 9 ,cov]age ,act4 #b4 ,promot+ gr\p heal? plan & gr\p heal? insurance cov]age price transp>5cy 7a7 ,9 g5]al 7#a7 ,,erisa 7,a7 ,9 g5]al ,section #gai ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe;h7 is am5d$ to read z foll[s3 #gai4 ,price transp>5cy requirem5ts 7a7 ,9 g5]al ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 %all make available to ! public accurate & timely disclosures ( ! foll[+ in=mation3 7#a7 ,claims paym5t policies & practices4 7#b7 ,p]iodic f9ancial disclosures4 7#c7 ,data on enrollm5t4 7#d7 ,data on dis5rollm5t4 7#e7 ,data on ! numb] ( claims t are d5i$4 7#f7 ,data on rat+ practices4 7#g7 ,in=mation on co/-%>+ & paym5ts ) respect to any out-(-network cov]age 7or ) respect to any item & s]vice furni%$ "u su* a plan or su* gr\p heal? insurance cov]age t does n use a network ( provid]s74 7#h7 ,in=mation on p>ticipant & b5efici>y rights "u ?is "p4 7#i7 ,rate & paym5t in=mation describ$ 9 subsection 7d74 7#aj7 ,o!r in=mation z det]m9$ appropriate by ! ,secret>y4 ,rate & paym5t in=mation describ$ 9 p>agraph 7#i7 %all be made available to ! public n lat] ?an ,janu>y #aj1 #bjbe1 & n lat] ?an ! t5? day ( e mon? !reaft]1 9 ! mann] describ$ 9 subsection 7d77#b77;,a71 &1 beg9n+ on ,janu>y #a1 #bjbg1 9 real-"t ?r\gh an application program int]face 7or successor te*nology7 describ$ 9 subsection 7d77#b77;,b74 7b7 ,use ( pla9 language ,! in=mation requir$ to be submitt$ "u subsection 7a7 %all be provid$ 9 pla9 language4 ,! t]m pla9 language means language t ! int5d$ audi5ce1 includ+ individuals ) limit$ ,engli% pr(ici5cy1 c readily und]/& & use because t language is cle>1 concise1 well-organiz$1 accurately describes ! in=mation1 & foll[s o!r be/ practices ( pla9 language writ+4 ,! ,secret>y1 jo9tly ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 %all develop & issue /&>ds = pla9 language writ+ = purposes ( ?is section & %all develop a /&>diz$ report+ template & /&>diz$ def9itions ( t]ms to all[ = comp>ison across gr\p heal? plans & heal? insurance cov]age4 7c7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 %all1 ^u reque/ ( a p>ticipant or b5efici>y & 9 a timely mann]1 provide to ! p>ticipant or b5efici>y a /atem5t ( ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! p>ticipant's or b5efici>y's plan or cov]age t ! p>ticipant or b5efici>y w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available at no co/ to ! p>ticipant or b5efici>y ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or ?r\gh a pap] or phone disclosure1 at ! option ( ! p>ticipant or b5efici>y1 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p heal? insurance cov]age 7z applicable7 furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan or cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7f77 = su* item or s]vice & = any o!r item or s]vice t is inh]5t 9 ! furni%+ ( ! item or s]vice t is ! subject ( su* reque/4 7,b7 ,if su* provid] is n a p>ticipat+ provid]1 ! all[$ am\nt1 p]c5tage ( bill$ *>ges1 or o!r rate t su* plan or cov]age w recognize z paym5t = su* item or s]vice1 along ) a notice t su* individual may be liable = additional *>ges bill$ by su* provid]4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! am\nt or rate describ$ 9 su* subp>agraph 7or1 9 ! case su* plan or issu] uses a p]c5tage ( bill$ *>ges to det]m9$ ! am\nt ( paym5t = su* provid]1 us+ a reasonable e/imate ( su* p]c5tage ( su* *>ges774 7,d7 ,! am\nt ! p>ticipant or b5efici>y has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate p>ticipants & b5efici>ies enroll$ 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,any %>$ sav+s or o!r b5efit available to ! p>ticipant or b5efici>y ) respect to su* item or s]vice4 7,f7 ,9 ! case su* plan or cov]age imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant or b5efici>y has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,g7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or gr\p heal? insurance cov]age4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website1 mobile application1 or o!r plat=m det]m9$ appropriate by ! ,secret>y2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* plan & su* item or s]vice = purposes ( facilitat+ price comp>isons2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 & 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to items & s]vices4 7#d7 ,provid] tool ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 %all p]mit provid]s to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t w\ld apply "u an individual's plan or cov]age t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by ano!r provid] 9 a timely mann] ^u ! reque/ ( ! provid] & ) ! cons5t ( su* individual 9 ! same mann] & to ! same ext5t z if su* reque/ has be5 made by su* individual4 ,z "p ( any tool us$ to facilitate su* reque/s f a provid]1 su* plan or issu] (f]+ heal? insurance cov]age may include functionality t-- 7,a7 all[s provid]s to submit ! notifications to su* plan or cov]age requir$ "u section #bgii;,b-#f ( ! ,public ,heal? ,s]vice ,act2 & 7,b7 provides = notifications requir$ "u section #gaf7;f7 to su* an individual4 7d7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= purposes ( subsection 7a77#i71 ! rate & paym5t in=mation describ$ 9 ?is subsection is1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age 7z applicable71 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age1 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* item or s]vice 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate74 7,b7 ,) respect to ea* dosage =m & indication ( ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan or cov]age-- 7i7 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* drug 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate72 & 7ii7 ! av]age am\nt paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan or cov]age4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan or cov]age1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan or cov]age dur+ su* p]iod4 ,su* rate & paym5t in=mation %all be made available ) respect to ea* individual item or s]vice1 reg>dless ( :e!r su* item or s]vice is paid = z "p ( a bundl$ paym5t1 episode ( c>e1 value-bas$ paym5t arrangem5t1 or o!rwise4 7#b7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u subsection 7a77#i7 %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#a7 t meet su* requirem5ts z specifi$ by ! ,secret>y n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is p>agraph ?r\gh rulemak+4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include in=mation t is duplicative ( in=mation conta9$ 9 ! same file or 9 o!r files made available "u su* subsection1 are made available 9 a widely-available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,real-"t provision ( in=mation 7i7 ,9 g5]al ,subject to clause 7ii71 beg9n+ ,janu>y #a1 #bjbf1 rate & paym5t in=mation requir$ to be made available by a gr\p heal? plan or heal? insurance issu] "u subsection 7a77#i7 %all1 9 addition to be+ made available 9 ! mann] describ$ 9 subp>agraph 7,a71 be made available ?r\gh an application program int]face 7or successor te*nology7 t provides access to su* in=mation 9 real "t & t meets su* te*nical /&>ds z may be specifi$ by ! ,secret>y4 7ii7 ,exemption = c]ta9 plans or cov]age ,clause 7i7 %all n apply ) respect to in=mation describ$ 9 su* clause requir$ to be made available by a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age if su* plan or cov]age1 z applicable1 provides b5efits = few] ?an #ejj p>ticipants & b5efici>ies4 7#c7 ,us] guide ,! ,secret>y1 ,secret>y ( ,heal? & ,human ,s]vices1 & ,secret>y ( ! ,treasury %all jo9tly make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#a7 9 files submitt$ 9 accordance ) p>agraph 7#b74 7#d7 ,annual summ>y ,= ea* ye> 7beg9n+ ) #bjbe71 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all make public a ma*9e-readable file meet+ su* /&>ds z e/abli%$ by ! ,secret>y "u p>agraph 7#b7 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan or issu] ) respect to su* plan or cov]age dur+ su* ye> 7su* z av]ages ( all su* in=mation s made public74 7e7 ,atte/ation ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation ( su* plan's or su* cov]age's compliance ) ! provisions ( ?is section along ) a l9k to disclosures made 9 accordance ) subsection 7a74 7f7 ,def9itions ,9 ?is subsection3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #gaf & includes a p>ticipat+ facility4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan or gr\p heal? insurance cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan or cov]age & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice4 4 7,b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( su* ,act is am5d$ by /rik+ ! item relat+ to section #gai & ins]t+ ! foll[+ new item3 ,sec4 #gai4 ,price transp>5cy requirem5ts4 4 7#b7 ,,irc 7,a7 ,9 g5]al ,section #ihai ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 #ihai4 ,price transp>5cy requirem5ts 7a7 ,9 g5]al ,a gr\p heal? plan %all make available to ! public accurate & timely disclosures ( ! foll[+ in=mation3 7#a7 ,claims paym5t policies & practices4 7#b7 ,p]iodic f9ancial disclosures4 7#c7 ,data on enrollm5t4 7#d7 ,data on dis5rollm5t4 7#e7 ,data on ! numb] ( claims t are d5i$4 7#f7 ,data on rat+ practices4 7#g7 ,in=mation on co/-%>+ & paym5ts ) respect to any out-(-network cov]age 7or ) respect to any item & s]vice furni%$ "u su* a plan t does n use a network ( provid]s74 7#h7 ,in=mation on p>ticipant & b5efici>y rights "u ?is "p4 7#i7 ,rate & paym5t in=mation describ$ 9 subsection 7d74 7#aj7 ,o!r in=mation z det]m9$ appropriate by ! ,secret>y4 ,rate & paym5t in=mation describ$ 9 p>agraph 7#i7 %all be made available to ! public n lat] ?an ,janu>y #aj1 #bjbe1 & n lat] ?an ! t5? day ( e mon? !reaft]1 9 ! mann] describ$ 9 subsection 7d77#b77;,a71 &1 beg9n+ on ,janu>y #a1 #bjbg1 9 real-"t ?r\gh an application program int]face 7or successor te*nology7 describ$ 9 subsection 7d77#b77;,b74 7b7 ,use ( pla9 language ,! in=mation requir$ to be submitt$ "u subsection 7a7 %all be provid$ 9 pla9 language4 ,! t]m pla9 language means language t ! int5d$ audi5ce1 includ+ individuals ) limit$ ,engli% pr(ici5cy1 c readily und]/& & use because t language is cle>1 concise1 well-organiz$1 accurately describes ! in=mation1 & foll[s o!r be/ practices ( pla9 language writ+4 ,! ,secret>y1 jo9tly ) ! ,secret>y ( ,heal? & ,human ,s]vices & ! ,secret>y ( ,labor1 %all develop & issue /&>ds = pla9 language writ+ = purposes ( ?is section & %all develop a /&>diz$ report+ template & /&>diz$ def9itions ( t]ms to all[ = comp>ison across gr\p heal? plans & heal? insurance cov]age4 7c7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,a gr\p heal? plan %all1 ^u reque/ ( a p>ticipant or b5efici>y & 9 a timely mann]1 provide to ! p>ticipant or b5efici>y a /atem5t ( ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! p>ticipant's or b5efici>y's plan t ! p>ticipant or b5efici>y w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available at no co/ to ! p>ticipant or b5efici>y ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or ?r\gh a pap] or phone disclosure1 at ! option ( ! p>ticipant or b5efici>y1 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan furni%$ by a heal? c>e provid] to a p>ticipant or b5efici>y ( su* plan1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7f77 = su* item or s]vice & = any o!r item or s]vice t is inh]5t 9 ! furni%+ ( ! item or s]vice t is ! subject ( su* reque/4 7,b7 ,if su* provid] is n a p>ticipat+ provid]1 ! all[$ am\nt1 p]c5tage ( bill$ *>ges1 or o!r rate t su* plan w recognize z paym5t = su* item or s]vice1 along ) a notice t su* individual may be liable = additional *>ges bill$ by su* provid]4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! p>ticipant or b5efici>y w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! am\nt or rate describ$ 9 su* subp>agraph 7or1 9 ! case su* plan uses a p]c5tage ( bill$ *>ges to det]m9$ ! am\nt ( paym5t = su* provid]1 us+ a reasonable e/imate ( su* p]c5tage ( su* *>ges774 7,d7 ,! am\nt ! p>ticipant or b5efici>y has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate p>ticipants & b5efici>ies enroll$ 9 ! plan1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,any %>$ sav+s or o!r b5efit available to ! p>ticipant or b5efici>y ) respect to su* item or s]vice4 7,f7 ,9 ! case su* plan imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* p>ticipant or b5efici>y has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,g7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website1 mobile application1 or o!r plat=m det]m9$ appropriate by ! ,secret>y2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* item or s]vice = purposes ( facilitat+ price comp>isons2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 & 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to items & s]vices4 7#d7 ,provid] tool ,a gr\p heal? plan %all p]mit provid]s to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t w\ld apply "u an individual's plan t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by ano!r provid] 9 a timely mann] ^u ! reque/ ( ! provid] & ) ! cons5t ( su* individual 9 ! same mann] & to ! same ext5t z if su* reque/ has be5 made by su* individual4 ,z "p ( any tool us$ to facilitate su* reque/s f a provid]1 su* plan may include functionality t-- 7,a7 all[s provid]s to submit ! notifications to su* plan or cov]age requir$ "u section #bgii;,b-#f ( ! ,public ,heal? ,s]vices ,act2 & 7,b7 provides = notifications requir$ "u section #ihaf7;f7 to su* an individual4 7d7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= purposes ( subsection 7a77#i71 ! rate & paym5t in=mation describ$ 9 ?is subsection is1 ) respect to a gr\p heal? plan1 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan1 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* item or s]vice 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate74 7,b7 ,) respect to ea* dosage =m & indication ( ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan-- 7i7 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* drug 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate72 & 7ii7 ! av]age am\nt paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan or cov]age4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan1 ! am\nt bill$1 & ! am\nt all[$ by ! plan1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan or cov]age dur+ su* p]iod4 ,su* rate & paym5t in=mation %all be made available ) respect to ea* individual item or s]vice1 reg>dless ( :e!r su* item or s]vice is paid = z "p ( a bundl$ paym5t1 episode ( c>e1 value-bas$ paym5t arrangem5t1 or o!rwise4 7#b7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u subsection 7a77#i7 %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#a7 t meet su* requirem5ts z specifi$ by ! ,secret>y n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is p>agraph ?r\gh rulemak+4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include in=mation t is duplicative ( in=mation conta9$ 9 o!r files made available "u su* subsection1 are made available 9 a widely-available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,real-"t provision ( in=mation 7i7 ,9 g5]al ,subject to clause 7ii71 beg9n+ ,janu>y #a1 #bjbf1 rate & paym5t in=mation requir$ to be made available by a gr\p heal? plan "u subsection 7a77#i7 %all1 9 addition to be+ made available 9 ! mann] describ$ 9 subp>agraph 7,a71 be made available ?r\gh an application program int]face 7or successor te*nology7 t provides access to su* in=mation 9 real "t & t meets su* te*nical /&>ds z may be specifi$ by ! ,secret>y4 7ii7 ,exemption = c]ta9 plans & cov]age ,clause 7i7 %all n apply ) respect to in=mation describ$ 9 su* clause requir$ to be made available by a gr\p heal? plan if su* plan provides b5efits = few] ?an #ejj p>ticipants & b5efici>ies4 7#c7 ,us] guide ,! ,secret>y1 ,secret>y ( ,heal? & ,human ,s]vices1 & ,secret>y ( ,labor %all jo9tly make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#a7 9 files submitt$ 9 accordance ) p>agraph 7#b74 7#d7 ,annual summ>y ,= ea* ye> 7beg9n+ ) #bjbe71 ea* gr\p heal? plan %all make public a ma*9e-readable file meet+ su* /&>ds z e/abli%$ by ! ,secret>y "u p>agraph 7#b7 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan ) respect to su* plan or cov]age dur+ su* ye> 7su* z av]ages ( all su* in=mation s made public74 7e7 ,atte/ation ,ea* gr\p heal? plan %all annually submit to ! ,secret>y an atte/ation ( su* plan's compliance ) ! provisions ( ?is section along ) a l9k to disclosures made 9 accordance ) subsection 7a74 7f7 ,def9itions ,9 ?is subsection3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #ihaf & includes a p>ticipat+ facility4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan & su* provid] = su* item or s]vice4 4 7,b7 ,cl]ical am5dm5t ,! item relat+ to section #ihai 9 ! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ to read z foll[s3 ,sec4 #ihai4 ,price transp>5cy requirem5ts4 4 7#c7 ,,phsa ,section #bgii;,a-#d ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aad7 is am5d$ to read z foll[s3 #bgii;,a-#d4 ,price transp>5cy requirem5ts 7a7 ,9 g5]al ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 %all make available to ! public accurate & timely disclosures ( ! foll[+ in=mation3 7#a7 ,claims paym5t policies & practices4 7#b7 ,p]iodic f9ancial disclosures4 7#c7 ,data on enrollm5t4 7#d7 ,data on dis5rollm5t4 7#e7 ,data on ! numb] ( claims t are d5i$4 7#f7 ,data on rat+ practices4 7#g7 ,in=mation on co/-%>+ & paym5ts ) respect to any out-(-network cov]age 7or ) respect to any item & s]vice furni%$ "u su* a plan or su* gr\p or individual heal? insurance cov]age t does n use a network ( provid]s74 7#h7 ,in=mation on enrollee rights "u ?is "p4 7#i7 ,rate & paym5t in=mation describ$ 9 subsection 7d74 7#aj7 ,o!r in=mation z det]m9$ appropriate by ! ,secret>y4 ,rate & paym5t in=mation describ$ 9 p>agraph 7#i7 %all be made available to ! public n lat] ?an ,janu>y #aj1 #bjbe1 & n lat] ?an ! t5? day ( e mon? !reaft]1 9 ! mann] describ$ 9 subsection 7d77#b77;,a71 &1 beg9n+ on ,janu>y #a1 #bjbg1 9 real-"t ?r\gh an application program int]face 7or successor te*nology7 describ$ 9 subsection 7d77#b77;,b74 7b7 ,use ( pla9 language ,! in=mation requir$ to be submitt$ "u subsection 7a7 %all be provid$ 9 pla9 language4 ,! t]m pla9 language means language t ! int5d$ audi5ce1 includ+ individuals ) limit$ ,engli% pr(ici5cy1 c readily und]/& & use because t language is cle>1 concise1 well-organiz$1 accurately describes ! in=mation1 & foll[s o!r be/ practices ( pla9 language writ+4 ,! ,secret>y1 jo9tly ) ! ,secret>y ( ,labor & ! ,secret>y ( ! ,treasury1 %all develop & issue /&>ds = pla9 language writ+ = purposes ( ?is section & %all develop a /&>diz$ report+ template & /&>diz$ def9itions ( t]ms to all[ = comp>ison across gr\p heal? plans & heal? insurance cov]age4 7c7 ,co/ %>+ transp>5cy 7#a7 ,9 g5]al ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 %all1 ^u reque/ ( an enrollee & 9 a timely mann]1 provide to ! enrollee a /atem5t ( ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 "u ! enrollee's plan or cov]age t ! enrollee w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by a provid]4 ,at a m9imum1 su* in=mation %all include ! in=mation specifi$ 9 p>agraph 7#b7 & %all be made available at no co/ to ! enrollee ?r\gh a self-s]vice tool t meets ! requirem5ts ( p>agraph 7#c7 or ?r\gh a pap] or phone disclosure1 at ! option ( ! enrollee1 t meets su* requirem5ts z ! ,secret>y may specify4 7#b7 ,specifi$ in=mation ,= purposes ( p>agraph 7#a71 ! in=mation specifi$ 9 ?is p>agraph is1 ) respect to an item or s]vice = :i* b5efits are available "u a gr\p heal? plan or gr\p or individual heal? insurance cov]age 7z applicable7 furni%$ by a heal? c>e provid] to an enrollee ( su* plan or cov]age1 ! foll[+3 7,a7 ,if su* provid] is a p>ticipat+ provid] ) respect to su* item or s]vice1 ! 9-network rate 7z def9$ 9 subsection 7f77 = su* item or s]vice & = any o!r item or s]vice t is inh]5t 9 ! furni%+ ( ! item or s]vice t is ! subject ( su* reque/4 7,b7 ,if su* provid] is n a p>ticipat+ provid]1 ! all[$ am\nt1 p]c5tage ( bill$ *>ges1 or o!r rate t su* plan or cov]age w recognize z paym5t = su* item or s]vice1 along ) a notice t su* enrollee may be liable = additional *>ges bill$ by su* provid]4 7,c7 ,! e/imat$ am\nt ( co/ %>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t ! enrollee w incur = su* item or s]vice 7:i*1 9 ! case su* item or s]vice is to be furni%$ by a provid] describ$ 9 subp>agraph 7,b71 %all be calculat$ us+ ! am\nt or rate describ$ 9 su* subp>agraph 7or1 9 ! case su* plan or issu] uses a p]c5tage ( bill$ *>ges to det]m9$ ! am\nt ( paym5t = su* provid]1 us+ a reasonable e/imate ( su* p]c5tage ( su* *>ges774 7,d7 ,! am\nt ! enrollee has already accumulat$ ) respect to any d$uctible or out ( pocket maximum "u ! plan or cov]age 7brok5 d[n1 9 ! case sep>ate d$uctibles or maximums apply to sep>ate enrollees 9 ! plan or cov]age1 by su* sep>ate d$uctibles or maximums1 9 addition to any cumulative d$uctible or maximum74 7,e7 ,any %>$ sav+s or o!r b5efit available to ! enrollee ) respect to su* item or s]vice4 7,f7 ,9 ! case su* plan or cov]age imposes any frequ5cy or volume limitations ) respect to su* item or s]vice 7exclud+ m$ical necessity det]m9ations71 ! am\nt t su* enrollee has accru$ t[>ds su* limitation ) respect to su* item or s]vice4 7,g7 ,any prior au?orization1 concurr5t review1 /ep !rapy1 fail fir/1 or simil> requirem5ts applicable to cov]age ( su* item or s]vice "u su* plan or gr\p or individual heal? insurance cov]age4 7#c7 ,self-s]vice tool ,= purposes ( p>agraph 7#a71 a self-s]vice tool e/abli%$ by a gr\p heal? plan or heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age meets ! requirem5ts ( ?is p>agraph if su* tool-- 7,a7 is bas$ on an ,int]net website1 mobile application1 or o!r plat=m det]m9$ appropriate by ! ,secret>y2 7,b7 provides = real-"t responses to reque/s describ$ 9 p>agraph 7#a72 7,c7 is updat$ 9 a mann] su* t in=mation provid$ ?r\gh su* tool is accurate at ! "t su* reque/ is made2 7,d7 all[s su* a reque/ to be made ) respect to an item or s]vice furni%$ by-- 7i7 a specific provid] t is a p>ticipat+ provid] ) respect to su* item or s]vice2 7ii7 all provid]s t are p>ticipat+ provid]s ) respect to su* plan & su* item or s]vice = purposes ( facilitat+ price comp>isons2 or 7iii7 a provid] t is n describ$ 9 clause 7ii72 & 7,e7 provides t su* a reque/ may be made ) respect to an item or s]vice ?r\gh use ( ! bill+ code = su* item or s]vice or ?r\gh use ( a descriptive t]m = su* item or s]vice4 ,! ,secret>y may require su* tool1 z a condition ( comply+ ) subp>agraph 7,e71 to l9k multiple bill+ codes to a s+le descriptive t]m if ! ,secret>y det]m9es t ! bill+ codes to be s l9k$ correspond to items & s]vices4 7#d7 ,provid] tool ,a gr\p heal? plan1 & a heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age1 %all p]mit provid]s to le>n ! am\nt ( co/-%>+ 7includ+ d$uctibles1 copaym5ts1 & co9surance7 t w\ld apply "u an individual's plan or cov]age t ! individual w\ld be responsible = pay+ ) respect to ! furni%+ ( a specific item or s]vice by ano!r provid] 9 a timely mann] ^u ! reque/ ( ! provid] & ) ! cons5t ( su* individual 9 ! same mann] & to ! same ext5t z if su* reque/ has be5 made by su* individual4 ,z "p ( any tool us$ to facilitate su* reque/s f a provid]1 su* plan or issu] (f]+ heal? insurance cov]age may include functionality t-- 7,a7 all[s provid]s to submit ! notifications to su* plan or cov]age requir$ "u section #bgii;,b-#f2 & 7,b7 provides = notifications requir$ "u section #bgii;,a-#a7;f7 to su* an individual4 7d7 ,rate & paym5t in=mation 7#a7 ,9 g5]al ,= purposes ( subsection 7a77#i71 ! rate & paym5t in=mation describ$ 9 ?is subsection is1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age 7z applicable71 ! foll[+3 7,a7 ,) respect to ea* item or s]vice 7o!r ?an a drug7 = :i* b5efits are available "u su* plan or cov]age1 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* item or s]vice 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate74 7,b7 ,) respect to ea* dosage =m & indication ( ea* drug 7id5tifi$ by national drug code7 = :i* b5efits are available "u su* plan or cov]age-- 7i7 ! 9-network rate 79 a doll> am\nt7 9 effect z ( ! fir/ day ( ! plan ye> dur+ :i* su* in=mation is submitt$ ) ea* provid] 7id5tifi$ by national provid] id5tifi]7 t is a p>ticipat+ provid] ) respect to su* drug 7or1 9 ! case su* rate is n available 9 a doll> am\nt1 su* =mulae1 pric+ me?odologies1 or o!r in=mation us$ to calculate su* rate72 & 7ii7 ! av]age am\nt paid by su* plan 7net ( rebates1 disc\nts1 & price concessions7 = su* drug disp5s$ or adm9i/]$ dur+ ! #ij-;day p]iod beg9n+ #ahj days be=e su* date ( submission to ea* provid] t 0 a p>ticipat+ provid] ) respect to su* drug1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an su* an am\nt paid to a provid] t1 dur+ su* p]iod1 submitt$ few] ?an #bj claims = su* drug to su* plan or cov]age4 7,c7 ,) respect to ea* item or s]vice = :i* b5efits are available "u su* plan or cov]age1 ! am\nt bill$1 & ! am\nt all[$ by ! plan or cov]age1 = ea* su* item or s]vice furni%$ dur+ ! #ij-;day p]iod specifi$ 9 subp>agraph 7,b7 by a provid] t 0 n a p>ticipat+ provid] ) respect to su* item or s]vice1 brok5 d[n by ea* su* provid] 7id5tifi$ by national provid] id5tifi]71 o!r ?an items & s]vices ) respect to :i* few] ?an #bj claims = su* item or s]vice 7 submitt$ to su* plan or cov]age dur+ su* p]iod4 ,su* rate & paym5t in=mation %all be made available ) respect to ea* individual item or s]vice1 reg>dless ( :e!r su* item or s]vice is paid = z "p ( a bundl$ paym5t1 episode ( c>e1 value-bas$ paym5t arrangem5t1 or o!rwise4 7#b7 ,mann] ( publication 7,a7 ,9 g5]al ,rate & paym5t in=mation requir$ to be made available "u subsection 7a77#i7 %all be s made available 9 doll> am\nts ?r\gh #c sep>ate ma*9e-readable files correspond+ to ! in=mation describ$ 9 ea* ( subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 7#a7 t meet su* requirem5ts z specifi$ by ! ,secret>y n lat] ?an #ahj days aft] ! date ( ! enactm5t ( ?is p>agraph ?r\gh rulemak+4 ,su* requirem5ts %all ensure t su* files are limit$ to an appropriate size1 d n include in=mation t is duplicative ( in=mation conta9$ 9 o!r files made available "u su* subsection1 are made available 9 a widely-available =mat t all[s = in=mation conta9$ 9 su* files to be comp>$ across gr\p heal? plans & gr\p or individual heal? insurance cov]age1 & are accessible to individuals at no co/ & )\t ! ne$ to e/abli% a us] acc\nt or provide o!r cr$5tials4 7,b7 ,real-"t provision ( in=mation 7i7 ,9 g5]al ,subject to clause 7ii71 beg9n+ ,janu>y #a1 #bjbf1 rate & paym5t in=mation requir$ to be made available by a gr\p heal? plan or heal? insurance issu] "u subsection 7a77#i7 %all1 9 addition to be+ made available 9 ! mann] describ$ 9 subp>agraph 7,a71 be made available ?r\gh an application program int]face 7or successor te*nology7 t provides access to su* in=mation 9 real "t & t meets su* te*nical /&>ds z may be specifi$ by ! ,secret>y4 7ii7 ,exemption = c]ta9 plans & cov]age ,clause 7i7 %all n apply ) respect to in=mation describ$ 9 su* clause requir$ to be made available by a gr\p heal? plan or heal? insurance issu] (f]+ heal? insurance cov]age if su* plan or cov]age1 z applicable1 provides b5efits = few] ?an #ejj enrollees4 7#c7 ,us] guide ,! ,secret>y1 ,secret>y ( ,labor1 & ,secret>y ( ! ,treasury %all jo9tly make available to ! public in/ructions writt5 9 pla9 language expla9+ h[ individuals may se>* = in=mation describ$ 9 p>agraph 7#a7 9 files submitt$ 9 accordance ) p>agraph 7#b74 7#d7 ,annual summ>y ,= ea* ye> 7beg9n+ ) #bjbe71 ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all make public a ma*9e-readable file meet+ su* /&>ds z e/abli%$ by ! ,secret>y "u p>agraph 7#b7 conta9+ a summ>y ( all rate & paym5t in=mation made public by su* plan or issu] ) respect to su* plan or cov]age dur+ su* ye> 7su* z av]ages ( all su* in=mation s made public74 7e7 ,atte/ation ,ea* gr\p heal? plan & heal? insurance issu] (f]+ gr\p or individual heal? insurance cov]age %all annually submit to ! ,secret>y an atte/ation ( su* plan's or su* cov]age's compliance ) ! provisions ( ?is section along ) a l9k to disclosures made 9 accordance ) subsection 7a74 7f7 ,def9itions ,9 ?is subsection3 7#a7 ,p>ticipat+ provid] ,! t]m p>ticipat+ provid] has ! mean+ giv5 su* t]m 9 section #bgii;,a-#a & includes a p>ticipat+ facility4 7#b7 ,9-network rate ,! t]m 9-network rate means1 ) respect to a gr\p heal? plan or gr\p or individual heal? insurance cov]age & an item or s]vice furni%$ by a provid] t is a p>ticipat+ provid] ) respect to su* plan or cov]age & item or s]vice1 ! contract$ rate 7reflect$ z a doll> am\nt7 9 effect betwe5 su* plan or cov]age & su* provid] = su* item or s]vice4 4 7b7 ,reports to ,congress 7#a7 ,quality report ,n lat] ?an #a ye> aft] ! date ( enactm5t ( ?is subsection1 ! ,secret>y ( ,labor %all submit to ,congress a report on ! feasibility ( includ+ data relat+ to ! quality ( heal? c>e items & s]vices ) ! price transp>5cy in=mation requir$ to be made available "u ! am5dm5ts made by subsection 7a74 ,su* report %all include recomm5dations = legislative & regulatory actions to id5tify appropriate metrics = assess+ & comp>+ quality ( c>e4 7#b7 ,transp>5cy data assessm5t ,n lat] ?an ,janu>y #a1 #bjbf1 & biannually !reaft] ?r\gh #bjcb1 ! ,secret>y %all submit to ,congress1 & make publicly available on a website ( ! ,dep>tm5t ( ,labor1 a report ) respect to ! in=mation describ$ 9 section #gai ( ! ,employee ,retirem5t ,income ,security ,act 7#bi ,u4,s4,c4 #aahe;h7 7z am5d$ by ! ,transp>5cy 9 ,cov]age ,act ( #bjbc71 assess+ ! diff]5ces 9 comm]cial negotiat$ prices-- 7,a7 betwe5 rural & urban m>kets2 7,b7 9 ! individual1 small-employ]1 & l>ge-employ] m>kets2 7,c7 9 consolidat$ & non-consolidat$ provid] m>kets2 7,d7 betwe5 non-pr(it & =-pr(it hospitals2 & 7,e7 betwe5 non-pr(it & =-pr(it insur]s4 7c7 ,effective date 7#a7 ,9 g5]al ,! am5dm5ts made by subsection 7a7 %all apply to plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe4 7#b7 ,cont9u$ applicability ( rules = previ\s ye>s ,no?+ 9 ! am5dm5ts made by subsection 7a7 may be con/ru$ z affect+ ! applicability ( ! rule entitl$ ,transp>5cy 9 ,cov]age publi%$ by ! ,dep>tm5t ( ! ,treasury1 ! ,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( ,heal? & ,human ,s]vices on ,novemb] #ab1 #bjbj 7#he ,f$4 ,reg4 #gbaeh7 = plan ye>s beg9n+ be=e ,janu>y #a1 #bjbe4 #c4 ,ph>macy b5efit manag] transp>5cy 7a7 ,,erisa 7#a7 ,9 g5]al ,subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajba et seq47 is am5d$-- 7,a7 9 subp>t ,b ( "p #g 7#bi ,u4,s4,c4 #aahe et seq471 by add+ at ! end ! foll[+3 #gbf4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 a gr\p heal? plan 7or heal? insurance issu] (f]+ gr\p heal? insurance cov]age 9 connection ) su* a plan7 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or issu] may n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 swit*1 pati5t or copay assi/ance program adm9i/rator1 ph>macy1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits or delays ! disclosure ( in=mation to plan adm9i/rators 9 su* a mann] t prev5ts ! plan or issu]1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan or issu]1 f mak+ or sub/antiat+ ! reports describ$ 9 subsection 7b74 7b7 ,reports 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 n less frequ5tly ?an qu>t]ly 7& ^u reque/ by ! plan adm9i/rator71 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan or an issu] provid+ gr\p heal? insurance cov]age1 %all submit to ! plan adm9i/rator 7z def9$ 9 section #c7af77;,a77 ( su* plan or cov]age a report 9 accordance ) ?is subsection1 & make su* report available to ! plan adm9i/rator 9 a ma*9e-readable =mat 7or z may be det]m9$ by ! ,secret>y1 o!r =mats74 ,ea* su* report %all include1 ) respect to ! applicable gr\p heal? plan or heal? insurance cov]age-- 7,a7 in=mation collect$ f a pati5t or copay assi/ance program adm9i/rator by su* entity on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 or o!r disc\nts t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants & b5efici>ies 9 su* plan or cov]age2 7,b7 total gross sp5d+ on prescription drugs by ! plan or cov]age dur+ ! report+ p]iod2 7,c7 total am\nt receiv$1 or expect$ to be receiv$1 by ! plan or cov]age f any entities1 9 rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! entity or any ?ird p>ty 7includ+ gr\p pur*as+ organizations7 o!r ?an ! plan adm9i/rator1 relat$ to utilization ( drug or drug sp5d+ "u su* plan or cov]age dur+ ! report+ p]iod2 7,d7 ! total net sp5d+ on prescription drugs by ! plan or cov]age dur+ su* report+ p]iod2 7,e7 am\nts paid1 directly or indirectly1 9 rebates1 fees1 or any o!r type ( comp5sation 7z def9$ 9 section #djh7;b77#b77;,b77ii77dd77,,aa77 to brok]age h\ses1 brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's or heal? insurance issu]'s bus9ess to ! ph>macy b5efits manag]1 id5tifi$ by ! recipi5t ( su* am\nts2 7,f7 7i7 an explanation ( any b5efit design p>amet]s t enc\rage or require p>ticipants & b5efici>ies 9 ! plan or cov]age to fill prescriptions at mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices "u su* plan or cov]age1 includ+ m&atory mail & specialty home deliv]y programs1 retail & mail auto-refill programs1 & co/-%>+ assi/ance inc5tives fund$ by an entity provid+ ph>macy b5efit managem5t s]vices2 7ii7 ! p]c5tage ( total prescriptions *>g$ to ! plan1 issu]1 or p>ticipants & b5efici>ies 9 su* plan or cov]age1 t 7 disp5s$ by mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices2 & 7iii7 a li/ ( all drugs disp5s$ by su* affiliat$ ph>macy or ph>macy "u common own]%ip & *>g$ to ! plan1 issu]1 or p>ticipants & b5efici>ies ( ! plan1 dur+ ! applicable p]iod1 &1 ) respect to ea* drug-- 7,i7 7aa7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 ) respect to p>ticipants & b5efici>ies 9 ! plan or cov]age1 to ! plan or issu]2 & 7bb7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 to p>ticipants & b5efici>ies2 7,,ii7 ! m$ian am\nt *>g$ to ! plan or issu]1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( su* plan or cov]age2 7,,iii7 ! int]qu>tile range ( ! co/s1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( t plan or cov]age2 7,,iv7 ! l[e/ co/1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan & p>ticipants & b5efici>ies1 t is available f any ph>macy includ$ 9 ! network ( ! plan or cov]age2 7,v7 ! net acquisition co/ p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 if ! drug is subject to a maximum price disc\nt2 & 7,,vi7 o!r in=mation ) respect to ! co/ ( ! drug1 z det]m9$ by ! ,secret>y1 su* z av]age sales price1 :olesale acquisition co/1 & national av]age drug acquisition co/ p] dosage unit or p] #cj-;day supply1 & p] #ij-;day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan or issu] & p>ticipants & b5efici>ies among all ph>macies includ$ 9 ! network ( su* plan or cov]age2 & 7,g7 9 ! case ( a l>ge employ]-- 7i7 a li/ ( ea* drug cov]$ by su* plan1 issu]1 or entity provid+ ph>macy b5efits managem5t s]vices = :i* a claim 0 fil$ dur+ ! report+ p]iod1 includ+1 ) respect to ea* su* drug dur+ ! report+ p]iod-- 7,i7 ! br& "n1 g5]ic or non-propriet>y "n1 & ! ,national ,drug ,code2 7,,ii7 7aa7 ! numb] ( p>ticipants & b5efici>ies = :om a claim = su* drug 0 fil$ dur+ ! report+ p]iod1 ! total numb] ( prescription claims = su* drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units & total days supply ( su* drug = :i* a claim 0 fil$ dur+ ! report+ p]iod2 & 7bb7 ) respect to ea* claim or dosage unit describ$ 9 item 7aa71 ! type ( disp5s+ *annel us$1 su* z retail1 mail ord]1 or specialty ph>macy2 7,,iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] dosage unit on date ( disp5s+2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies on su* drug aft] application ( any b5efits "u su* plan or cov]age1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles 7b n includ+ any am\nts sp5t by p>ticipants & b5efici>ies on drugs n cov]$ "u su* plan or cov]age1 or = :i* no claim 0 submitt$ to su* plan or cov]age72 7,v7 = any drug = :i* gross sp5d+ ( ! plan or cov]age exce$$ #aj1jjj dur+ ! report+ p]iod-- 7aa7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs1 biological products1 g5]ic drugs1 or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7bb7 ! rationale = pref]r$ =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 & 7ii7 a li/ ( ea* !rapeutic category or class ( drugs = :i* a claim 0 fil$ "u ! heal? plan or heal? insurance cov]age dur+ ! report+ p]iod1 &1 ) respect to ea* su* !rapeutic category or class ( drugs dur+ ! report+ p]iod-- 7,i7 total gross sp5d+ by ! plan2 7,,ii7 ! numb] ( p>ticipants & b5efici>ies :o fill$ a prescription = a drug 9 t category or class2 7,,iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization me*anisms 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 & 7,v7 = ea* drug-- 7aa7 ! am\nt receiv$1 or expect$ to be receiv$1 f any entity 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation-- 7,,aa7 = claims incurr$ dur+ ! report+ p]iod2 or 7,,bb7 t is relat$ to utilization ( drugs or drug sp5d+2 7bb7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! heal? plan or heal? insurance cov]age on t category or class ( drugs2 & 7cc7 ! av]age net sp5d+ p] #cj-;day supply & p] #ij-;day supply1 incurr$ by ! heal? plan or heal? insurance cov]age & its p>ticipants & b5efici>ies1 among all drugs )9 ! !rapeutic class = :i* a claim 0 fil$ dur+ ! report+ p]iod4 7#b7 ,privacy requirem5ts ,heal? insurance issu]s (f]+ gr\p heal? insurance cov]age & entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan adm9i/rators :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan adm9i/rator "u p>agraph 7#a7 ) respect to su* cov]age or plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e74 7#e7 ,/&>d =mat ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = heal? insurance issu]s & entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a heal? insurance issu]1 gr\p heal? plan1 or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,dep>tm5t ( ,labor to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 by su* issu]1 plan1 or entity4 7d7 ,def9itions ,9 ?is section3 7#a7 ,l>ge employ] ,! t]m l>ge employ] means1 9 connection ) a gr\p heal? plan ) respect to a cal5d> ye> & a plan ye>1 an employ] :o employ$ an av]age ( at lea/ #ej employees on bus9ess days dur+ ! prec$+ cal5d> ye> & :o employs at lea/ #a employee on ! fir/ day ( ! plan ye>4 7#b7 ,:olesale acquisition co/ ,! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 2 & 7,b7 9 section #ejb 7#bi ,u4,s4,c4 #aacb7-- 7i7 9 subsection 7a7-- 7,i7 9 p>agraph 7#f71 by /rik+ or 7#i7 & ins]t+ 7#i71 or 7#ac72 7,,ii7 9 p>agraph 7#aj71 by /rik+ at ! end or2 7,,iii7 9 p>agraph 7#aa71 at ! end by /rik+ ! p]iod & ins]t+ 2 or2 & 7,,iv7 by add+ at ! end ! foll[+ new p>agraph3 7#ab7 by ! ,secret>y1 to en=ce section #gbf4 2 7ii7 9 subsection 7b77#c71 by ins]t+ & subsections 7a77#ab7 & 7c77#ac7 be=e 1 ! ,secret>y is n2 & 7iii7 9 subsection 7c71 by add+ at ! end ! foll[+ new p>agraph3 7#ac7 ,secret>ial en=cem5t au?ority relat+ to ov]sight ( ph>macy b5efits manag] s]vices 7,a7 ,failure to provide timely in=mation ,! ,secret>y may impose a p5alty aga9/ any heal? insurance issu] or entity provid+ ph>macy b5efits managem5t s]vices t violates section #gbf7;a7 or fails to provide in=mation requir$ "u section #gbf7;b7 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7,b7 ,false in=mation ,! ,secret>y may impose a p5alty aga9/ a heal? insurance issu] or entity provid+ ph>macy b5efits managem5t s]vices t kn[+ly provides false in=mation "u section #gbf 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7,c7 ,waiv]s ,! ,secret>y may waive p5alties "u subp>agraph 7,a71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( section #gbf1 = an entity 9 violation ( su* section t has made a good-fai? ef=t to comply ) su* section4 4 7#b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq47 is am5d$ by ins]t+ aft] ! item relat+ to section #gbe ! foll[+ new item3 ,sec4 #gbf4 ,ov]sight ( ph>macy b5efits manag] s]vices4 4 7b7 ,,phsa ,"p ,d ( title ,,xxvii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg-#aaa et seq47 is am5d$ by add+ at ! end ! foll[+ new section3 #bgii;,a-#aa4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 a gr\p heal? plan 7or heal? insurance issu] (f]+ gr\p heal? insurance cov]age 9 connection ) su* a plan7 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan or issu] may n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 swit*1 pati5t or copay assi/ance program adm9i/rator1 ph>macy1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits or delays ! disclosure ( in=mation to plan adm9i/rators 9 su* a mann] t prev5ts ! plan or issu]1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan or issu]1 f mak+ or sub/antiat+ ! reports describ$ 9 subsection 7b74 7b7 ,reports 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 n less frequ5tly ?an qu>t]ly 7& ^u reque/ by ! plan adm9i/rator71 a gr\p heal? plan or heal? insurance issu] (f]+ gr\p heal? insurance cov]age1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan or an issu] provid+ gr\p heal? insurance cov]age1 %all submit to ! plan adm9i/rator 7z def9$ 9 section #c7af77;,a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 ( su* plan or cov]age a report 9 accordance ) ?is subsection1 & make su* report available to ! plan adm9i/rator 9 a ma*9e-readable =mat 7or z may be det]m9$ by ! ,secret>y1 o!r =mats74 ,ea* su* report %all include1 ) respect to ! applicable gr\p heal? plan or heal? insurance cov]age-- 7,a7 in=mation collect$ f a pati5t or copay assi/ance program adm9i/rator by su* entity on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 or o!r disc\nts t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants & b5efici>ies 9 su* plan or cov]age2 7,b7 total gross sp5d+ on prescription drugs by ! plan or cov]age dur+ ! report+ p]iod2 7,c7 total am\nt receiv$1 or expect$ to be receiv$1 by ! plan or cov]age f any entities1 9 rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! entity or any ?ird p>ty 7includ+ gr\p pur*as+ organizations7 o!r ?an ! plan adm9i/rator1 relat$ to utilization ( drug or drug sp5d+ "u su* plan or cov]age dur+ ! report+ p]iod2 7,d7 ! total net sp5d+ on prescription drugs by ! plan or cov]age dur+ su* report+ p]iod2 7,e7 am\nts paid1 directly or indirectly1 9 rebates1 fees1 or any o!r type ( comp5sation 7z def9$ 9 section #djh7;b77#b77;,b77ii77dd77,,aa7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 to brok]age h\ses1 brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's or heal? insurance issu]'s bus9ess to ! ph>macy b5efits manag]1 id5tifi$ by ! recipi5t ( su* am\nts2 7,f7 7i7 an explanation ( any b5efit design p>amet]s t enc\rage or require p>ticipants & b5efici>ies 9 ! plan or cov]age to fill prescriptions at mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices "u su* plan or cov]age1 includ+ m&atory mail & specialty home deliv]y programs1 retail & mail auto-refill programs1 & co/-%>+ assi/ance inc5tives fund$ by an entity provid+ ph>macy b5efit managem5t s]vices2 7ii7 ! p]c5tage ( total prescriptions *>g$ to ! plan1 issu]1 or p>ticipants & b5efici>ies 9 su* plan or cov]age1 t 7 disp5s$ by mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices2 & 7iii7 a li/ ( all drugs disp5s$ by su* affiliat$ ph>macy or ph>macy "u common own]%ip & *>g$ to ! plan1 issu]1 or p>ticipants & b5efici>ies ( ! plan1 dur+ ! applicable p]iod1 &1 ) respect to ea* drug-- 7,i7 7aa7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 ) respect to p>ticipants & b5efici>ies 9 ! plan or cov]age1 to ! plan or issu]2 & 7bb7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 to p>ticipants & b5efici>ies2 7,,ii7 ! m$ian am\nt *>g$ to ! plan or issu]1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( su* plan or cov]age2 7,,iii7 ! int]qu>tile range ( ! co/s1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( t plan or cov]age2 7,,iv7 ! l[e/ co/1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan & p>ticipants & b5efici>ies1 t is available f any ph>macy includ$ 9 ! network ( ! plan or cov]age2 7,v7 ! net acquisition co/ p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 if ! drug is subject to a maximum price disc\nt2 & 7,,vi7 o!r in=mation ) respect to ! co/ ( ! drug1 z det]m9$ by ! ,secret>y1 su* z av]age sales price1 :olesale acquisition co/1 & national av]age drug acquisition co/ p] dosage unit or p] #cj-;day supply1 & p] #ij-;day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan or issu] & p>ticipants & b5efici>ies among all ph>macies includ$ 9 ! network ( su* plan or cov]age2 & 7,g7 9 ! case ( a l>ge employ]-- 7i7 a li/ ( ea* drug cov]$ by su* plan1 issu]1 or entity provid+ ph>macy b5efits managem5t s]vices = :i* a claim 0 fil$ dur+ ! report+ p]iod1 includ+1 ) respect to ea* su* drug dur+ ! report+ p]iod-- 7,i7 ! br& "n1 g5]ic or non-propriet>y "n1 & ! ,national ,drug ,code2 7,,ii7 7aa7 ! numb] ( p>ticipants & b5efici>ies = :om a claim = su* drug 0 fil$ dur+ ! report+ p]iod1 ! total numb] ( prescription claims = su* drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units & total days supply ( su* drug = :i* a claim 0 fil$ dur+ ! report+ p]iod2 & 7bb7 ) respect to ea* claim or dosage unit describ$ 9 item 7aa71 ! type ( disp5s+ *annel us$1 su* z retail1 mail ord]1 or specialty ph>macy2 7,,iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] dosage unit on date ( disp5s+2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies on su* drug aft] application ( any b5efits "u su* plan or cov]age1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles 7b n includ+ any am\nts sp5t by p>ticipants & b5efici>ies on drugs n cov]$ "u su* plan or cov]age1 or = :i* no claim 0 submitt$ to su* plan or cov]age72 7,v7 = any drug = :i* gross sp5d+ ( ! plan or cov]age exce$$ #aj1jjj dur+ ! report+ p]iod-- 7aa7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs1 biological products1 g5]ic drugs1 or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7bb7 ! rationale = pref]r$ =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 & 7ii7 a li/ ( ea* !rapeutic category or class ( drugs = :i* a claim 0 fil$ "u ! heal? plan or heal? insurance cov]age dur+ ! report+ p]iod1 &1 ) respect to ea* su* !rapeutic category or class ( drugs dur+ ! report+ p]iod-- 7,i7 total gross sp5d+ by ! plan2 7,,ii7 ! numb] ( p>ticipants & b5efici>ies :o fill$ a prescription = a drug 9 t category or class2 7,,iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization me*anisms 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 & 7,v7 = ea* drug-- 7aa7 ! am\nt receiv$1 or expect$ to be receiv$1 f any entity 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation-- 7,,aa7 = claims incurr$ dur+ ! report+ p]iod2 or 7,,bb7 t is relat$ to utilization ( drugs or drug sp5d+2 7bb7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! heal? plan or heal? insurance cov]age on t category or class ( drugs2 & 7cc7 ! av]age net sp5d+ p] #cj-;day supply & p] #ij-;day supply1 incurr$ by ! heal? plan or heal? insurance cov]age & its p>ticipants & b5efici>ies1 among all drugs )9 ! !rapeutic class = :i* a claim 0 fil$ dur+ ! report+ p]iod4 7#b7 ,privacy requirem5ts ,heal? insurance issu]s (f]+ gr\p heal? insurance cov]age & entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* issu] or entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan adm9i/rators :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,a heal? insurance issu] (f]+ gr\p heal? insurance cov]age or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan adm9i/rator "u p>agraph 7#a7 ) respect to su* cov]age or plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e74 7#e7 ,/&>d =mat ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = heal? insurance issu]s & entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,en=cem5t 7#a7 ,failure to provide timely in=mation ,an entity provid+ ph>macy b5efits managem5t s]vices t violates subsection 7a7 or fails to provide in=mation requir$ "u subsection 7b7 %all be subject to a civil monet>y p5alty 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7#b7 ,false in=mation ,an entity provid+ ph>macy b5efits managem5t s]vices t kn[+ly provides false in=mation "u ?is section %all be subject to a civil money p5alty 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* civil money p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7#c7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act1 o!r ?an subsection 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* section %all apply to civil monet>y p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u section #aabh;,a ( ! ,social ,security ,act4 7#d7 ,waiv]s ,! ,secret>y may waive p5alties "u p>agraph 7#b71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( ?is section1 = an entity 9 violation ( ?is section t has made a good-fai? ef=t to comply ) ?is section4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a heal? insurance issu]1 gr\p heal? plan1 or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,dep>tm5t ( ,heal? & ,human ,s]vices to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 by su* issu]1 plan1 or entity4 7e7 ,def9itions ,9 ?is section3 7#a7 ,l>ge employ] ,! t]m l>ge employ] means1 9 connection ) a gr\p heal? plan ) respect to a cal5d> ye> & a plan ye>1 an employ] :o employ$ an av]age ( at lea/ #ej employees on bus9ess days dur+ ! prec$+ cal5d> ye> & :o employs at lea/ #a employee on ! fir/ day ( ! plan ye>4 7#b7 ,:olesale acquisition co/ ,! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 4 7c7 ,,irc 7#a7 ,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new section3 #ihbf4 ,ov]sight ( ph>macy b5efits manag] s]vices 7a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 a gr\p heal? plan or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( su* a plan may n ent] into a contract ) a drug manufactur]1 di/ributor1 :olesal]1 swit*1 pati5t or copay assi/ance program adm9i/rator1 ph>macy1 subcontractor1 rebate aggregator1 or any associat$ ?ird p>ty t limits or delays ! disclosure ( in=mation to plan adm9i/rators 9 su* a mann] t prev5ts ! plan1 or an entity or subsidi>y provid+ ph>macy b5efits managem5t s]vices on behalf ( a plan1 f mak+ or sub/antiat+ ! reports describ$ 9 subsection 7b74 7b7 ,reports 7#a7 ,9 g5]al ,= plan ye>s beg9n+ on or aft] ,janu>y #a1 #bjbe1 n less frequ5tly ?an qu>t]ly 7& ^u reque/ by ! plan adm9i/rator71 a gr\p heal? plan1 or an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan1 %all submit to ! plan adm9i/rator 7z def9$ 9 section #c7af77;,a7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 ( su* plan a report 9 accordance ) ?is subsection1 & make su* report available to ! plan adm9i/rator 9 a ma*9e-readable =mat 7or z may be det]m9$ by ! ,secret>y1 o!r =mats74 ,ea* su* report %all include1 ) respect to ! applicable gr\p heal? plan-- 7,a7 in=mation collect$ f a pati5t or copay assi/ance program adm9i/rator by su* entity on ! total am\nt ( copaym5t assi/ance doll>s paid1 or copaym5t c>ds appli$1 or o!r disc\nts t 7 fund$ by ! drug manufactur] ) respect to ! p>ticipants & b5efici>ies 9 su* plan2 7,b7 total gross sp5d+ on prescription drugs by ! plan dur+ ! report+ p]iod2 7,c7 total am\nt receiv$1 or expect$ to be receiv$1 by ! plan f any entities1 9 rebates1 fees1 alt]native disc\nts1 & all o!r remun]ation receiv$ f ! entity or any ?ird p>ty 7includ+ gr\p pur*as+ organizations7 o!r ?an ! plan adm9i/rator1 relat$ to utilization ( drug or drug sp5d+ "u su* plan dur+ ! report+ p]iod2 7,d7 ! total net sp5d+ on prescription drugs by ! plan dur+ su* report+ p]iod2 7,e7 am\nts paid1 directly or indirectly1 9 rebates1 fees1 or any o!r type ( comp5sation 7z def9$ 9 section #djh7;b77#b77;,b77ii77dd77,,aa7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd7 to brok]age h\ses1 brok]s1 consultants1 advisors1 or any o!r individual or firm = ! ref]ral ( ! gr\p heal? plan's bus9ess to ! ph>macy b5efits manag]1 id5tifi$ by ! recipi5t ( su* am\nts2 7,f7 7i7 an explanation ( any b5efit design p>amet]s t enc\rage or require p>ticipants & b5efici>ies 9 ! plan to fill prescriptions at mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices "u su* plan1 includ+ m&atory mail & specialty home deliv]y programs1 retail & mail auto-refill programs1 & co/-%>+ assi/ance inc5tives fund$ by an entity provid+ ph>macy b5efit managem5t s]vices2 7ii7 ! p]c5tage ( total prescriptions *>g$ to ! plan1 or p>ticipants & b5efici>ies 9 su* plan1 t 7 disp5s$ by mail ord]1 specialty1 or retail ph>macies t are affiliat$ ) or "u common own]%ip ) ! entity provid+ ph>macy b5efit managem5t s]vices2 & 7iii7 a li/ ( all drugs disp5s$ by su* affiliat$ ph>macy or ph>macy "u common own]%ip & *>g$ to ! plan1 or p>ticipants & b5efici>ies ( ! plan1 dur+ ! applicable p]iod1 &1 ) respect to ea* drug-- 7,i7 7aa7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 ) respect to p>ticipants & b5efici>ies 9 ! plan1 to ! plan2 & 7bb7 ! am\nt *>g$1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 to p>ticipants & b5efici>ies2 7,,ii7 ! m$ian am\nt *>g$ to ! plan1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( su* plan2 7,,iii7 ! int]qu>tile range ( ! co/s1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 includ+ am\nts paid by ! p>ticipants & b5efici>ies1 :5 ! same drug is disp5s$ by o!r ph>macies t are n affiliat$ ) or "u common own]%ip ) ! entity & t are includ$ 9 ! ph>macy network ( t plan2 7,,iv7 ! l[e/ co/1 p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan & p>ticipants & b5efici>ies1 t is available f any ph>macy includ$ 9 ! network ( ! plan2 7,v7 ! net acquisition co/ p] dosage unit1 p] #cj-;day supply1 & p] #ij-;day supply1 if ! drug is subject to a maximum price disc\nt2 & 7,,vi7 o!r in=mation ) respect to ! co/ ( ! drug1 z det]m9$ by ! ,secret>y1 su* z av]age sales price1 :olesale acquisition co/1 & national av]age drug acquisition co/ p] dosage unit or p] #cj-;day supply1 & p]-#ij day supply1 = su* drug1 includ+ am\nts *>g$ to ! plan & p>ticipants & b5efici>ies among all ph>macies includ$ 9 ! network ( su* plan2 & 7,g7 9 ! case ( a l>ge employ]-- 7i7 a li/ ( ea* drug cov]$ by su* plan or entity provid+ ph>macy b5efits managem5t s]vices = :i* a claim 0 fil$ dur+ ! report+ p]iod1 includ+1 ) respect to ea* su* drug dur+ ! report+ p]iod-- 7,i7 ! br& "n1 g5]ic or non-propriet>y "n1 & ! ,national ,drug ,code2 7,,ii7 7aa7 ! numb] ( p>ticipants & b5efici>ies = :om a claim = su* drug 0 fil$ dur+ ! report+ p]iod1 ! total numb] ( prescription claims = su* drug 7includ+ orig9al prescriptions & refills71 & ! total numb] ( dosage units & total days supply ( su* drug = :i* a claim 0 fil$ dur+ ! report+ p]iod2 & 7bb7 ) respect to ea* claim or dosage unit describ$ 9 item 7aa71 ! type ( disp5s+ *annel us$1 su* z retail1 mail ord]1 or specialty ph>macy2 7,,iii7 ! :olesale acquisition co/1 li/$ z co/ p] days supply & co/ p] dosage unit on date ( disp5s+2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies on su* drug aft] application ( any b5efits "u su* plan1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles 7b n includ+ any am\nts sp5t by p>ticipants & b5efici>ies on drugs n cov]$ "u su* plan1 or = :i* no claim 0 submitt$ to su* plan72 7,v7 = any drug = :i* gross sp5d+ ( ! plan exce$$ #aj1jjj dur+ ! report+ p]iod-- 7aa7 a li/ ( all o!r drugs 9 ! same !rapeutic category or class1 includ+ br& "n drugs1 biological products1 g5]ic drugs1 or biosimil> biological products t are 9 ! same !rapeutic category or class z su* drug2 & 7bb7 ! rationale = pref]r$ =mul>y placem5t ( su* drug 9 t !rapeutic category or class1 if applicable2 & 7ii7 a li/ ( ea* !rapeutic category or class ( drugs = :i* a claim 0 fil$ "u ! plan dur+ ! report+ p]iod1 &1 ) respect to ea* su* !rapeutic category or class ( drugs dur+ ! report+ p]iod-- 7,i7 total gross sp5d+ by ! plan2 7,,ii7 ! numb] ( p>ticipants & b5efici>ies :o fill$ a prescription = a drug 9 t category or class2 7,,iii7 if applicable to t category or class1 a description ( ! =mul>y ti]s & utilization me*anisms 7su* z prior au?orization or /ep !rapy7 employ$ = drugs 9 t category or class2 7,,iv7 ! total out-(-pocket sp5d+ by p>ticipants & b5efici>ies1 includ+ p>ticipant & b5efici>y sp5d+ ?r\gh copaym5ts1 co9surance1 & d$uctibles2 & 7,v7 = ea* drug-- 7aa7 ! am\nt receiv$1 or expect$ to be receiv$1 f any entity 9 rebates1 fees1 alt]native disc\nts1 or o!r remun]ation-- 7,,aa7 = claims incurr$ dur+ ! report+ p]iod2 or 7,,bb7 t is relat$ to utilization ( drugs or drug sp5d+2 7bb7 ! total net sp5d+1 aft] d$uct+ rebates1 price concessions1 alt]native disc\nts or o!r remun]ation f drug manufactur]s1 by ! plan on t category or class ( drugs2 & 7cc7 ! av]age net sp5d+ p] #cj-;day supply & p] #ij-;day supply1 incurr$ by ! plan & its p>ticipants & b5efici>ies1 among all drugs )9 ! !rapeutic class = :i* a claim 0 fil$ dur+ ! report+ p]iod4 7#b7 ,privacy requirem5ts ,entities provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all provide in=mation "u p>agraph 7#a7 9 a mann] consi/5t ) ! privacy1 security1 & brea* notification regulations promulgat$ "u section #bfd7;c7 ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 & %all re/rict ! use & disclosure ( su* in=mation accord+ to su* privacy regulations4 7#c7 ,disclosure & r$isclosure 7,a7 ,limitation to bus9ess associates ,a gr\p heal? plan receiv+ a report "u p>agraph 7#a7 may disclose su* in=mation only to bus9ess associates ( su* plan z def9$ 9 section #afj4ajc ( title #de1 ,code ( ,f$]al ,regulations 7or successor regulations74 7,b7 ,cl>ification reg>d+ public disclosure ( in=mation ,no?+ 9 ?is section prev5ts an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan f plac+ reasonable re/rictions on ! public disclosure ( ! in=mation conta9$ 9 a report describ$ 9 p>agraph 7#a71 except t su* entity may n re/rict disclosure ( su* report to ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 ! ,dep>tm5t ( ,labor1 ! ,dep>tm5t ( ! ,treasury1 ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates1 or applicable ,/ate ag5cies4 7,c7 ,limit$ =m ( report ,! ,secret>y %all def9e ?r\gh rulemak+ a limit$ =m ( ! report "u p>agraph 7#a7 requir$ ( plan adm9i/rators :o are drug manufactur]s1 drug :olesal]s1 or o!r direct p>ticipants 9 ! drug supply *a91 9 ord] to prev5t anti-competitive behavior4 7#d7 ,report to ,,gao ,an entity provid+ ph>macy b5efits managem5t s]vices on behalf ( a gr\p heal? plan %all submit to ! ,comptroll] ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/ #d reports submitt$ to a plan adm9i/rator "u p>agraph 7#a7 ) respect to su* plan1 & o!r su* reports z reque/$1 9 accordance ) ! privacy requirem5ts "u p>agraph 7#b71 ! disclosure & r$isclosure /&>ds "u p>agraph 7#c71 ! /&>ds specifi$ pursuant to p>agraph 7#e74 7#e7 ,/&>d =mat ,n lat] ?an #f mon?s aft] ! date ( enactm5t ( ?is section1 ! ,secret>y %all specify ?r\gh rulemak+ /&>ds = entities requir$ to submit reports "u p>agraph 7#d7 to submit su* reports 9 a /&>d =mat4 7c7 ,en=cem5t 7#a7 ,failure to provide timely in=mation ,an entity provid+ ph>macy b5efits managem5t s]vices t violates subsection 7a7 or fails to provide in=mation requir$ "u subsection 7b7 %all be subject to a civil monet>y p5alty 9 ! am\nt ( #aj1jjj = ea* day dur+ :i* su* violation cont9ues or su* in=mation is n disclos$ or report$4 7#b7 ,false in=mation ,an entity provid+ ph>macy b5efits managem5t s]vices t kn[+ly provides false in=mation "u ?is section %all be subject to a civil money p5alty 9 an am\nt n to exce$ #ajj1jjj = ea* item ( false in=mation4 ,su* civil money p5alty %all be 9 addition to o!r p5alties z may be prescrib$ by law4 7#c7 ,proc$ure ,! provisions ( section #aabh;,a ( ! ,social ,security ,act1 o!r ?an subsection 7a7 & 7b7 & ! fir/ s5t5ce ( subsection 7c77#a7 ( su* section %all apply to civil monet>y p5alties "u ?is subsection 9 ! same mann] z su* provisions apply to a p5alty or proce$+ "u section #aabh;,a ( ! ,social ,security ,act4 7#d7 ,waiv]s ,! ,secret>y may waive p5alties "u p>agraph 7#b71 or ext5d ! p]iod ( "t = compliance ) a requirem5t ( ?is section1 = an entity 9 violation ( ?is section t has made a good-fai? ef=t to comply ) ?is section4 7d7 ,rule ( con/ruction ,no?+ 9 ?is section %all be con/ru$ to p]mit a gr\p heal? plan1 or o!r entity to re/rict disclosure to1 or o!rwise limit ! access (1 ! ,dep>tm5t ( ! ,treasury to a report describ$ 9 subsection 7b77#a7 or in=mation relat$ to compliance ) subsection 7a7 by su* plan or entity4 7e7 ,def9itions ,9 ?is section3 7#a7 ,l>ge employ] ,! t]m l>ge employ] means1 9 connection ) a gr\p heal? plan ) respect to a cal5d> ye> & a plan ye>1 an employ] :o employ$ an av]age ( at lea/ #ej employees on bus9ess days dur+ ! prec$+ cal5d> ye> & :o employs at lea/ #a employee on ! fir/ day ( ! plan ye>4 7#b7 ,:olesale acquisition co/ ,! t]m :olesale acquisition co/ has ! mean+ giv5 su* t]m 9 section #ahdg;,a7c77#f77;,b7 ( ! ,social ,security ,act4 4 7#b7 ,cl]ical am5dm5t ,! table ( sections = sub*apt] ,b ( *apt] #ajj ( ! ,int]nal ,rev5ue ,code ( #aihf is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #ihbf4 ,ov]sight ( ph>macy b5efits manag] s]vices4 4 #d4 ,in=mation on prescription drugs 7a7 ,9 g5]al ,subp>t ,b ( "p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aahe et seq471 z am5d$ by section #c1 is fur!r am5d$ by add+ at ! end ! foll[+ new section3 #gbg4 ,in=mation on prescription drugs 7a7 ,9 g5]al ,a gr\p heal? plan or a heal? insurance issu] (f]+ gr\p heal? insurance cov]age %all-- 7#a7 n re/rict1 directly or indirectly1 any ph>macy t disp5ses a prescription drug to a p>ticipant ( b5efici>y 9 ! plan or cov]age f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u ! plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any heal? plan or heal? insurance cov]age2 & 7#b7 ensure t any entity t provides ph>macy b5efits managem5t s]vices "u a contract ) any su* heal? plan or heal? insurance cov]age does n1 ) respect to su* plan or cov]age1 re/rict1 directly or indirectly1 a ph>macy t disp5ses a prescription drug f in=m+ 7or p5alize su* ph>macy = in=m+7 a p>ticipant or b5efici>y ( any diff]5tial betwe5 ! p>ticipant's or b5efici>y's out-(-pocket co/ "u ! plan or cov]age ) respect to acquisition ( ! drug & ! am\nt an individual w\ld pay = acquisition ( ! drug )\t us+ any heal? plan or heal? insurance cov]age4 7b7 ,def9ition ,= purposes ( ?is section1 ! t]m out-(-pocket co/1 ) respect to acquisition ( a drug1 means ! am\nt to be paid by ! p>ticipant or b5efici>y "u ! plan or cov]age1 includ+ any co/-%>+ 7includ+ any d$uctible1 copaym5t1 or co9surance7 &1 z det]m9$ by ! ,secret>y1 any o!r exp5diture4 4 7b7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajja et seq471 z am5d$ by section #c1 is fur!r am5d$ by ins]t+ aft] ! item relat+ to section #gbf ! foll[+ new item3 ,sec4 #gbg4 ,in=mation on prescription drugs4 4 #e4 ,advisory committee on ! accessibility ( c]ta9 in=mation 7a7 ,9 g5]al ,n lat] ?an ,janu>y #a1 #bjbe1 ! ,secret>y ( ,labor 79 ?is section ref]r$ to z ! ,secret>y7 %all conv5e an ,advisory ,committee 79 ?is section ref]r$ to z ! ,committee7 consi/+ ( #i memb]s to advise ! ,secret>y on h[ to improve ! accessibility & usability ( in=mation made available 9 accordance ! am5dm5ts made by section #c & by section #bjd ( division ,,bb ( ! ,consolidat$ ,appropriation ,act1 #bjba 7,public ,law #aaf-bfj71 /reaml9e ! report+ ( su* in=mation1 & ensure t su* in=mation fully meets ! ne$s ( employ]s1 pati5ts1 rese>*]s1 regulators1 & pur*as]s4 7b7 ,memb]%ip ,! ,secret>y %all appo9t memb]s repres5t+ end-us]s ( ! in=mation describ$ 9 subsection 7a74 ,vacancies on ! ,committee %all be fill$ by appo9tm5t consi/5t ) ?is subsection n lat] ?an #c mon?s aft] ! vacancy arises4 7c7 ,t]m9ation ,! ,committee e/abli%$ "u ?is section %all t]m9ate on ,janu>y #a1 #bjbh4 ,decemb] #ai1 #bjbd ,committees on ,en]gy & ,comm]ce & ,ways & ,means dis*>g$2 committ$ to ! ,committee ( ! ,:ole ,h\se on ! ,/ate ( ! ,union & ord]$ to be pr9t$