#aah? ,,congress  #a/ ,session  ,h4 ,r4 
#ecgh  ,,an ,,act  ,to promote price    
transp>5cy 9 ! heal? c>e sector1 & = o!r
 purposes4  #a4 ,%ort title ,?is ,act   
may be cit$ z ! ,l[] ,co/s1 ,m          
,transp>5cy ,act4  #b4 ,table ( cont5ts 
,! table ( cont5ts ( ?is ,act is z      
foll[s3  ,sec4 #a4 ,%ort title4 ,sec4   
#b4 ,table ( cont5ts4 ,title            
,i--,improv+ ,heal? ,c>e ,transp>5cy    
,sec4 #aja4 ,hospital price transp>5cy4 
,sec4 #ajb4 ,cl9ical diagno/ic          
laboratory te/ price transp>5cy4 ,sec4  
#ajc4 ,imag+ price transp>5cy4 ,sec4    
#ajd4 ,ambulatory surgical c5t] price   
transp>5cy4 ,sec4 #aje4 ,heal? cov]age  
price transp>5cy4 ,sec4 #ajf4 ,ph>macy  
b5efits price transp>5cy4 ,sec4 #ajg4   
,reports on heal? c>e transp>5cy tools &
 data4 ,sec4 #ajh4 ,report on           
integration 9 ,m$ic>e4 ,sec4 #aji4      
,advisory ,committee4 ,sec4 #aaj4       
,report on impact ( ,m$ic>e regulations 
on provid] & pay] consolidation4 ,sec4  
#aaa4 ,implem5tation fund+4 ,title      

,,ii--,r$uc+ ,heal? ,c>e ,co/s =        
,pati5ts ,sec4 #bja4 ,increas+          
transp>5cy 9 g5]ic drug applications4   
,sec4 #bjb4 ,improv+ transp>5cy &       
prev5t+ ! use ( abusive spread pric+ &  
relat$ practices 9 ,m$icaid4 ,sec4 #bjc4
 ,p>ity 9 ,m$ic>e paym5ts = hospital    
outpati5t dep>tm5t s]vices furni%$      
(f-campus4 ,sec4 #bjd4 ,requir+ a       
sep>ate id5tification numb] & an        
atte/ation = ea* (f-campus outpati5t    
dep>tm5t ( a provid]4 ,title            
,,iii--,support+ ,pati5ts1 ,heal? ,c>e  
,work]s1 ,community ,heal? ,c5t]s1 &    
,hospitals ,sec4 #cja4 ,ext5sion =      
community heal? c5t]s1 ! national heal? 
s]vice corps1 & tea*+ heal? c5t]s t     
op]ate ,,gme programs4 ,sec4 #cjb4      
,ext5sion ( special diabetes programs4  
,sec4 #cjc4 ,delay+ c]ta9               
disproportionate %>e paym5t cuts4 ,sec4 
#cjd4 ,m$icaid improvem5t fund4 ,title  
,,iv--,increas+ access to quality heal? 
data & l[]+ hidd5 fees ,sec4 #dja4      
,increas+ ,plan ,fiduci>ies' ,access to 

,heal? ,data4 ,sec4 #djb4 ,hidd5 ,fees  
,disclosure ,requirem5ts4 ,sec4 #djc4   
,prescription drug price in=mation      
requirem5t4 ,sec4 #djd4 ,implem5tation  
fund+4  ,i ,improv+ ,heal? ,c>e         
,transp>5cy  #aja4 ,hospital price      
transp>5cy  7a7 ,m$ic>e ,"p ,e ( title  
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #aciex et seq47 is am5d$ by   
add+ at ! end ! foll[+ new section3     
#ahii;,c4 ,hospital price transp>5cy    
7a7 ,transp>5cy requirem5t  7#a7 ,9     
g5]al ,beg9n+ ,janu>y #a1 #bjbf1 ea*    
specifi$ hospital t receives paym5t "u  
?is title = furni%+ items & s]vices %all
 comply ) ! price transp>5cy requirem5t 
describ$ 9 p>agraph 7#b74  7#b7         
,requirem5t describ$  7,a7 ,9 g5]al ,=  
purposes ( p>agraph 7#a71 ! price       
transp>5cy requirem5t describ$ 9 ?is    
p>agraph is1 ) respect to a specifi$    
hospital1 t su* hospital1 9 accordance )
 a me?od & =mat e/abli%$ by ! ,secret>y 
"u subp>agraph 7,c71 compile & make     
public 7)\t subscription & free ( *>ge7 

= ea* ye>-- 7i7 all ( ! hospital's /&>d 
*>ges 7includ+ ! in=mation describ$ 9   
subp>agraph 7,b77 = ea* item & s]vice   
furni%$ by su* hospital2  7ii7 in=mation
 9 a consum]-fri5dly =mat 7z specifi$ by
 ! ,secret>y7-- 7,i7 on ! hospital's    
prices 7includ+ ! in=mation describ$ 9  
subp>agraph 7,b77 = z _m ( ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices-specifi$     
%oppable s]vices t are furni%$ by !     
hospital1 & z _m additional             
hospital-select$ %oppable s]vices 7or   
all su* additional s]vices1 if su*      
hospital furni%es few] ?an #cjj %oppable
 s]vices7 z may be necess>y = a comb9$  
total ( at lea/ #cjj %oppable s]vices2 &
  7,,ii7 t includes1 ) respect to ea*   
,c5t]s = ,m$ic>e  ,m$icaid              
,s]vices-specifi$ %oppable s]vice t is n
 furni%$ by ! hospital1 an indication t 
su* s]vice is n s furni%$2 &  7iii7 an  
atte/ation t all in=mation made public  
pursuant to ?is subp>agraph is complete 
& accurate4  7,b7 ,in=mation describ$ ,=
 purposes ( subp>agraph 7,a71 !         

in=mation describ$ 9 ?is subp>agraph is1
 ) respect to /&>d *>ges & prices1 z    
applicable1 made public by a specifi$   
hospital1 ! foll[+3 7i7 ,a pla9 language
 description ( ea* item or s]vice1      
accompani$ by1 z applicable1 ! ,heal?c>e
 ,common ,proc$ure ,cod+ ,sy/em code1 ! 
diagnosis-relat$ gr\p1 ! national drug  
code1 or o!r id5tifi] us$ or approv$ by 
! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4  
7ii7 ,! gross *>ge1 z applicable1       
express$ z a doll> am\nt1 = ea* su* item
 or s]vice1 :5 provid$ 91 z applicable1 
! inpati5t sett+ & outpati5t dep>tm5t   
sett+4  7iii7 ,! disc\nt$ ca% price1 z  
applicable1 express$ z a doll> am\nt1 = 
ea* su* item or s]vice :5 provid$ 91 z  
applicable1 ! inpati5t sett+ & outpati5t
 dep>tm5t sett+ 7or1 9 ! case no        
disc\nt$ ca% price is available = an    
item or s]vice1 ! m$ian ca% price *>g$  
by ! hospital to self-pay individuals = 
su* item or s]vice :5 provid$ 9 su*     
sett+s = ! previ\s ?ree ye>s1 express$ z
 a doll> am\nt1 z well z1 ) respect to  

prices made public pursuant to          
subp>agraph 7,a77ii71 a l9k to a        
consum]-fri5dly docum5t t cle>ly expla9s
 ! hospital's *>ity c>e policy t        
includes1 if applicable1 any slid+ scale
 paym5t /ructure employ$ = det]m9+ *>ges
 = a self-pay individual74  7iv7 ,!     
pay]-specific negotiat$ *>ges1 z        
applicable1 cle>ly associat$ ) ! "n ( ! 
?ird p>ty pay] & plan & express$ z a    
doll> am\nt1 t apply to ea* su* item or 
s]vice :5 provid$ 91 z applicable1 !    
inpati5t sett+ & outpati5t dep>tm5t     
sett+4  7v7 ,! de-id5tifi$ maximum &    
m9imum negotiat$ *>ges1 z applicable1 = 
ea* su* item or s]vice4  7vi7 ,any o!r  
additional in=mation ! ,secret>y may    
require = ! purpose ( improv+ ! accuracy
 (1 or enabl+ consum]s to easily und]/& 
& comp>e1 /&>d *>ges & prices = an item 
or s]vice1 except in=mation t is        
duplicative ( any o!r report+ requirem5t
 "u ?is subsection4  ,9 ! case ( /&>d   
*>ges & prices = an item or s]vice      
includ$ z "p ( a bundl$1 p] diem1       

episodic1 or o!r simil> arrangem5t1 !   
in=mation describ$ 9 ?is subp>agraph    
%all be made available z det]m9$        
appropriate by ! ,secret>y4  7,c7 ,uni=m
 me?od & =mat ,n lat] ?an ,janu>y #a1   
#bjbf1 ! ,secret>y %all e/abli% a /&>d1 
uni=m me?od & =mat = specifi$ hospitals 
to use 9 compil+ & mak+ public /&>d     
*>ges pursuant to subp>agraph 7,a77i7 & 
a /&>d1 uni=m me?od & =mat = su*        
hospitals to use 9 compil+ & mak+ public
 prices pursuant to subp>agraph         
7,a77ii74 ,su* me?ods & =mats--  7i7    
%all1 9 ! case ( su* me?od & =mat = mak+
 public /&>d *>ges pursuant to          
subp>agraph 7,a77i71 ensure t su* *>ges 
are made available 9 a ma*9e-readable   
=mat 7or a successor te*nology specifi$ 
by ! ,secret>y72  7ii7 may be simil> to 
any template made available by ! ,c5t]s 
= ,m$ic>e  ,m$icaid ,s]vices z ( ! date 
( ! enactm5t ( ?is subp>agraph2  7iii7  
%all meet su* /&>ds z det]m9$           
appropriate by ! ,secret>y 9 ord] to    
ensure ! accessibility & usability ( su*

 *>ges & prices2 &  7iv7 %all be updat$ 
z det]m9$ appropriate by ! ,secret>y1 9 
consultation ) /akehold]s4  7#c7        
,monitor+ compliance ,! ,secret>y %all1 
?r\gh notice & comm5t rulemak+ & 9      
consultation ) ! ,inspector ,g5]al ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1   
e/abli% a process to monitor compliance 
) ?is subsection4 ,su* process %all     
ensure t ea* specifi$ hospital's        
compliance ) ?is subsection is review$ n
 less frequ5tly ?an once e #c ye>s4     
7#d7 ,en=cem5t  7,a7 ,9 g5]al ,9 ! case 
( a specifi$ hospital t fails to comply 
) ! requirem5ts ( ?is subsection--  7i7 
n lat] ?an #cj days aft] ! date on :i* !
 ,secret>y det]m9es su* failure exi/s1 !
 ,secret>y %all submit to su* hospital a
 notification ( su* det]m9ation 7:i* may
 include1 z det]m9$ appropriate by !    
,secret>y1 a reque/ = a corrective      
action plan to comply ) su*             
requirem5ts72 &  7ii7 9 ! case ( a      
hospital t does n receive a reque/ = a  
corrective action plan z "p ( a         

notification submitt$ by ! ,secret>y "u 
clause 7i7--  7,i7 ! ,secret>y %all1 n  
lat] ?an #de days aft] su* notification 
is s5t1 det]m9e :e!r su* hospital is 9  
compliance ) su* requirem5ts2 &  7,,ii7 
if ! ,secret>y det]m9es "u subclause    
7,i7 t su* hospital is n 9 compliance ) 
su* requirem5ts1 ! ,secret>y %all ei!r--
  7aa7 submit to su* hospital a reque/ =
 a corrective action plan to comply )   
su* requirem5ts2 or  7bb7 if ! ,secret>y
 det]m9es t su* hospital has n tak5     
mean+ful actions to come into compliance
 s9ce su* notification 0 s5t1 impose a  
civil monet>y p5alty 9 accordance )     
subp>agraph 7,b74  7,b7 ,civil monet>y  
p5alty  7i7 ,9 g5]al ,subject to clause 
7vii71 9 addition to any o!r en=cem5t   
actions or p5alties t may apply "u ano!r
 provision ( law1 a specifi$ hospital t 
has receiv$ a reque/ = a corrective     
action plan "u clause 7i7 or 7ii7 (     
subp>agraph 7,a7 & fails to comply ) !  
requirem5ts ( ?is subsection by ! date t
 is #de days aft] su* reque/ is made1 & 

a specifi$ hospital ) respect to :i* !  
,secret>y has made a det]m9ation        
describ$ 9 clause 7ii77,,ii77bb7 ( su*  
subp>agraph1 %all be subject to a civil 
monet>y p5alty ( an am\nt specifi$ by ! 
,secret>y = ea* day 7beg9n+ ) ! day on  
:i* ! ,secret>y fir/ det]m9$ t su*      
hospital 0 n comply+ ) su* requirem5ts7 
dur+ :i* su* failure 0 ongo+4 ,su* am\nt
 %all n exce$-- 7,i7 9 ! case ( a       
specifi$ hospital ) #cj or few] b$s1    
#cjj p] day 7or1 9 ! case ( su* a       
hospital t has be5 noncompliant ) su*   
requirem5ts = a #a-ye> p]iod or long]1  
beg9n+ ) ! fir/ day foll[+ su* #a-ye>   
p]iod1 #djj p] day72  7,,ii7 9 ! case ( 
a specifi$ hospital ) m ?an #cj b$s b   
few] ?an #aja b$s1 #ab4ej p] b$ p] day  
7or1 9 ! case ( su* a hospital t has be5
 noncompliant ) su* requirem5ts = a     
#a-ye> p]iod or long]1 beg9n+ ) ! fir/  
day foll[+ su* #a-ye> p]iod1 #ae p] b$  
p] day72  7,,iii7 9 ! case ( a specifi$ 
hospital ) m ?an #ajj b$s b few] ?an    
#bja b$s1 #ag4ej p] b$ p] day 7or1 9 !  

case ( su* a hospital t has be5         
noncompliant ) su* requirem5ts = a      
#a-ye> p]iod or long]1 beg9n+ ) ! fir/  
day foll[+ su* #a-ye> p]iod1 #bj p] b$  
p] day72  7,,iv7 9 ! case ( a specifi$  
hospital ) m ?an #bjj b$s b few] ?an    
#eja b$s1 #bj p] b$ p] day 7or1 9 ! case
 ( su* a hospital t has be5 noncompliant
 ) su* requirem5ts = a #a-ye> p]iod or  
long]1 beg9n+ ) ! fir/ day foll[+ su*   
#a-ye> p]iod1 #be p] b$ p] day72 &  7,v7
 9 ! case ( a specifi$ hospital ) m ?an 
#ejj b$s1 #be p] b$ p] day 7or1 9 ! case
 ( su* a hospital t has be5 noncompliant
 ) su* requirem5ts = a #a-ye> p]iod or  
long]1 beg9n+ ) ! fir/ day foll[+ su*   
#a-ye> p]iod1 #ce p] b$ p] day74  7ii7  
,increase au?ority ,9 apply+ ?is        
subp>agraph ) respect to violations     
occurr+ 9 #bjbg or a subsequ5t ye>1 !   
,secret>y may ?r\gh notice & comm5t     
rulemak+ increase-- 7,i7 ! limitation on
 ! p] day am\nt ( any p5alty applicable 
to a specifi$ hospital "u clause        
7i77,i72  7,,ii7 ! limitations on ! p]  

b$ p] day am\nt ( any p5alty applicable 
"u any ( subclauses 7,,ii7 ?r\gh 7,v7 ( 
clause 7i72 &  7,,iii7 ! am\nts specifi$
 9 clause 7iii77,,ii74  7iii7 ,p]si/5t  
noncompliance  7,i7 ,9 g5]al ,9 ! case (
 a specifi$ hospital 7o!r ?an a specifi$
 hospital ) #cj or few] b$s7 t !        
,secret>y has det]m9$ to be kn[+ly &    
willfully noncompliant ) ! provisions ( 
?is subsection two or m times dur+ a    
#a-ye> p]iod1 ! ,secret>y may increase  
any p5alty o!rwise applicable "u ?is    
subp>agraph by ! am\nt specifi$ 9       
subclause 7,,ii7 ) respect to su*       
hospital & may require su* hospital to  
complete su* additional corrective      
actions plans z ! ,secret>y may specify4
  7,,ii7 ,specifi$ am\nt ,= purposes (  
subclause 7,i71 ! am\nt specifi$ 9 ?is  
subclause is1 ) respect to a specifi$   
hospital--  7aa7 ) m ?an #cj b$s b few] 
?an #aja b$s1 an am\nt t is n less ?an  
#ejj1jjj & n m ?an #a1jjj1jjj2  7bb7 ) m
 ?an #ajj b$s b few] ?an #cja b$s1 an   
am\nt t is great] ?an #a1jjj1jjj & n m  

?an #b1jjj1jjj2  7cc7 ) m ?an #cjj b$s b
 few] ?an #eja b$s1 an am\nt t is great]
 ?an #b1jjj1jjj & n m ?an #d1jjj1jjj2 & 
7dd7 ) m ?an #ejj b$s1 & am\nt t is n   
less ?an #e1jjj1jjj & n m ?an           
#aj1jjj1jjj4  7iv7 ,au?ority to waive or
 r$uce p5alty  7,i7 ,9 g5]al ,subject to
 subclause 7,,ii71 ! ,secret>y may waive
 any p5alty1 or r$uce any p5alty by n m 
?an #ge p]c5t1 o!rwise applicable "u ?is
 subp>agraph ) respect to a specifi$    
hospital locat$ 9 a rural or und]s]v$   
area if ! ,secret>y c]tifies t          
imposition ( su* p5alty w\ld result 9 an
 imm$iate ?reat to access to c>e =      
individuals 9 ! s]vice area ( su*       
hospital4  7,,ii7 ,limitation on        
application ,! ,secret>y may n elect to 
waive a p5alty "u subclause 7,i7 )      
respect to a specifi$ hospital m ?an    
once 9 a #f-ye> p]iod & may n elect to  
r$uce su* a p5alty ) respect to su* a   
hospital m ?an once 9 su* a p]iod4 ,no?+
 9 ! prec$+ s5t5ce %all be con/ru$ z    
prohibit+ ! ,secret>y f bo? waiv+ &     

r$uc+ a p5alty ) respect to a specifi$  
hospital dur+ a #f-ye> p]iod4  7v7      
,provision ( te*nical assi/ance ,!      
,secret>y %all1 to ! ext5t practicable1 
provide te*nical assi/ance relat+ to    
compliance ) ! provisions ( ?is         
subsection to specifi$ hospitals reque/+
 su* assi/ance4  7vi7 ,application (    
c]ta9 provisions ,! provisions ( section
 #aabh;,a 7o!r ?an subsections 7a7 & 7b7
 ( su* section7 %all apply to a civil   
monet>y p5alty impos$ "u ?is subp>agraph
 9 ! same mann] z su* provisions apply  
to a civil monet>y p5alty impos$ "u     
subsection 7a7 ( su* section4  7vii7    
,nonduplication ( c]ta9 p5alties ,!     
,secret>y may n subject a specifi$      
hospital to a civil monet>y p5alty "u   
?is subp>agraph ) respect to            
noncompliance ) ! provisions ( ?is      
section = a p]iod if ! ,secret>y has    
impos$ a civil monet>y p5alty on su*    
hospital "u section #bgah7;f7 ( !       
,public ,heal? ,s]vice ,act = failure to
 comply ) ! provisions ( su* section =  

su* p]iod4  7,c7 ,publication ( hospital
 price transp>5cy in=mation ,beg9n+ on  
,janu>y #a1 #bjbf1 ! ,secret>y %all make
 publicly available on ! public website 
( ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices 
in=mation ) respect to compliance ) !   
requirem5ts ( ?is subsection & en=cem5t 
activities und]tak5 by ! ,secret>y "u   
?is subsection4 ,su* in=mation %all be  
updat$ 9 real "t & include--  7i7 !     
numb] ( reviews ( compliance ) ?is      
subsection und]tak5 by ! ,secret>y2     
7ii7 ! numb] ( notifications describ$ 9 
subp>agraph 7,a77i7 s5t by ! ,secret>y2 
7iii7 ! id5tity ( ea* specifi$ hospital 
t 0 s5t su* a notification & a          
description ( ! nature ( su* hospital's 
noncompliance ) ?is subsection2  7iv7 ! 
am\nt ( any civil monet>y p5alty impos$ 
on su* hospital "u subp>agraph 7,b72    
7v7 :e!r su* hospital subsequ5tly came  
into compliance ) ?is subsection2  7vi7 
any waiv]s or r$uctions ( p5alties made 
pursuant to a c]tification by !         
,secret>y "u subp>agraph 7,b77iv71      

includ+--  7,i7 ! "n ( any specifi$     
hospital t receiv$ su* a waiv] or       
r$uction2  7,,ii7 ! doll> am\nt ( ea*   
su* p5alty s waiv$ or r$uc$2 &  7,,iii7 
! rationale = ! grant+ ( ea* su* waiv]  
or r$uction2 &  7vii7 any o!r in=mation 
z det]m9$ by ! ,secret>y4  7b7 ,ensur+  
accessibility ?r\gh implem5tation ,9    
implem5t+ ! am5dm5ts made by ?is        
section1 ! ,secret>y ( ,heal? & ,human  
,s]vices %all ?r\gh rulemak+ ensure t a 
hospital submitt+ *>ges & in=mation     
pursuant to su* am5dm5ts takes          
reasonable /eps 7z specifi$ by !        
,secret>y7 to ensure ! accessibility (  
su* *>ges & in=mation to individuals )  
limit$ ,engli% pr(ici5cy4 ,su* /eps may 
include ! hospital's provision (        
int]pretation s]vices or ! hospital's   
provision ( translations ( *>ges &      
in=mation4  7c7 ,def9itions ,= purposes 
( ?is section3  7#a7 ,disc\nt$ ca% price
 ,! t]m disc\nt$ ca% price means ! *>ge 
t applies to an individual :o pays ca%1 
or ca% equival5t1 = an item or s]vice4  

7#b7 ,f$]al heal? c>e program ,! t]m    
,f$]al heal? c>e program has ! mean+    
giv5 su* t]m 9 section #aabh;,b4  7#c7  
,gross *>ge ,! t]m gross *>ge means !   
*>ge = an individual item or s]vice t is
 reflect$ on a specifi$ hospital's or   
provid] ( s]vice's or suppli]'s1 z      
applicable1 *>gema/]1 abs5t any         
disc\nts4  7#d7 ,gr\p heal? plan2 gr\p  
heal? insurance cov]age2 individual     
heal? insurance cov]age ,! t]ms gr\p    
heal? plan1 gr\p heal? insurance        
cov]age1 & individual heal? insurance   
cov]age h ! mean+ giv5 su* t]ms 9       
section #bgia ( ! ,public ,heal? ,s]vice
 ,act4  7#e7 ,pay]-specific negotiat$   
*>ge ,! t]m pay]-specific negotiat$ *>ge
 means ! *>ge t a specifi$ hospital or  
provid] ( s]vices or suppli]1 z         
applicable1 has negotiat$ ) a ?ird p>ty 
pay] = an item or s]vice4  7#f7         
,%oppable s]vice ,! t]m %oppable s]vice 
means a s]vice t c be s*$ul$ by a heal? 
c>e consum] 9 advance & includes all    
ancill>y items & s]vices cu/om>ily      

furni%$ z "p ( su* s]vice4  7#g7        
,specifi$ hospital ,! t]m specifi$      
hospital means a hospital 7z def9$ 9    
section #ahfa7;e771 a critical access   
hospital 7z def9$ 9 section             
#ahfa7mmm77#a771 or a rural em]g5cy     
hospital 7z def9$ 9 section #ahfa7kkk774
  7#h7 ,?ird p>ty pay] ,! t]m ?ird p>ty 
pay] means an entity t is1 by /atute1   
contract1 or agreem5t1 legally          
responsible = paym5t ( a claim = a heal?
 c>e item or s]vice4  4  7b7 ,,phsa     
7#a7 ,9 g5]al ,section #bgah ( ! ,public
 ,heal? ,s]vice ,act 7#db ,u4,s4,c4     
#cjj;gg-#ah7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7f7 ,hospital  
transp>5cy requirem5t  7#a7 ,9 g5]al    
,beg9n+ ,janu>y #a1 #bjbf1 ea* hospital 
%all comply ) ! price transp>5cy        
requirem5t describ$ 9 p>agraph 7#b74    
7#b7 ,requirem5t describ$  7,a7 ,9 g5]al
 ,= purposes ( p>agraph 7#a71 ! price   
transp>5cy requirem5t describ$ 9 ?is    
p>agraph is1 ) respect to a hospital1 t 
su* hospital1 9 accordance ) a me?od &  

=mat e/abli%$ by ! ,secret>y "u         
subp>agraph 7,c71 compile & make public 
7)\t subscription & free ( *>ge7 = ea*  
ye>-- 7i7 all ( ! hospital's /&>d *>ges 
7includ+ ! in=mation describ$ 9         
subp>agraph 7,b77 = ea* item & s]vice   
furni%$ by su* hospital2  7ii7 in=mation
 9 a consum]-fri5dly =mat 7z specifi$ by
 ! ,secret>y7-- 7,i7 on ! hospital's    
prices 7includ+ ! in=mation describ$ 9  
subp>agraph 7,b77 = z _m ( ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices-specifi$     
%oppable s]vices t are furni%$ by !     
hospital1 & z _m additional             
hospital-select$ %oppable s]vices 7or   
all su* additional s]vices1 if su*      
hospital furni%es few] ?an #cjj %oppable
 s]vices7 z may be necess>y = a comb9$  
total ( at lea/ #cjj %oppable s]vices2 &
  7,,ii7 t includes1 ) respect to ea*   
,c5t]s = ,m$ic>e  ,m$icaid              
,s]vices-specifi$ %oppable s]vice t is n
 furni%$ by ! hospital1 an indication t 
su* s]vice is n s furni%$2 &  7iii7 an  
atte/ation t all in=mation made public  

pursuant to ?is subp>agraph is complete 
& accurate4  7,b7 ,in=mation describ$ ,=
 purposes ( subp>agraph 7,a71 !         
in=mation describ$ 9 ?is subp>agraph is1
 ) respect to /&>d *>ges & prices1 z    
applicable1 made public by a hospital1 !
 foll[+3 7i7 ,a pla9 language           
description ( ea* item or s]vice1       
accompani$ by1 z applicable1 ! ,heal?c>e
 ,common ,proc$ure ,cod+ ,sy/em code1 ! 
diagnosis-relat$ gr\p1 ! national drug  
code1 curr5t proc$ure t]m9ology codes1  
or o!r id5tifi] us$ or approv$ by !     
,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4    
7ii7 ,! gross *>ge1 z applicable1       
express$ z a doll> am\nt1 = ea* su* item
 or s]vice1 :5 provid$ 91 z applicable1 
! inpati5t sett+ & outpati5t dep>tm5t   
sett+4  7iii7 ,! disc\nt$ ca% price1 z  
applicable1 express$ z a doll> am\nt1 = 
ea* su* item or s]vice :5 provid$ 91 z  
applicable1 ! inpati5t sett+ & outpati5t
 dep>tm5t sett+ 7or1 9 ! case no        
disc\nt$ ca% price is available = an    
item or s]vice1 ! m$ian ca% price *>g$  

by ! hospital to self-pay individuals = 
su* item or s]vice :5 provid$ 9 su*     
sett+s = ! previ\s ?ree ye>s1 express$ z
 a doll> am\nt1 z well z1 ) respect to  
prices made public pursuant to          
subp>agraph 7,a77ii71 a l9k to a        
consum]-fri5dly docum5t t cle>ly expla9s
 ! hospital's *>ity c>e policy t        
includes1 if applicable1 any slid+ scale
 paym5t /ructure employ$ = det]m9+ *>ges
 = a self-pay individual74  7iv7 ,!     
pay]-specific negotiat$ *>ges1 z        
applicable1 cle>ly associat$ ) ! "n ( ! 
?ird p>ty pay] & plan & express$ z a    
doll> am\nt1 t apply to ea* su* item or 
s]vice :5 provid$ 91 z applicable1 !    
inpati5t sett+ & outpati5t dep>tm5t     
sett+4  7v7 ,! de-id5tifi$ maximum &    
m9imum negotiat$ *>ges1 z applicable1 = 
ea* su* item or s]vice4  7vi7 ,any o!r  
additional in=mation ! ,secret>y may    
require = ! purpose ( improv+ ! accuracy
 (1 or enabl+ consum]s to easily und]/& 
& comp>e1 /&>d *>ges & prices = an item 
or s]vice1 except in=mation t is        

duplicative ( any o!r report+ requirem5t
 "u ?is subsection4  ,9 ! case ( /&>d   
*>ges & prices = an item or s]vice      
includ$ z "p ( a bundl$1 p] diem1       
episodic1 or o!r simil> arrangem5t1 !   
in=mation describ$ 9 ?is subp>agraph    
%all be made available z det]m9$        
appropriate by ! ,secret>y4  7,c7 ,uni=m
 me?od & =mat ,n lat] ?an ,janu>y #a1   
#bjbf1 ! ,secret>y %all e/abli% a /&>d1 
uni=m me?od & =mat = hospitals to use 9 
compil+ & mak+ public /&>d *>ges        
pursuant to subp>agraph 7,a77i7 & a     
/&>d1 uni=m me?od & =mat = su* hospitals
 to use 9 compil+ & mak+ public prices  
pursuant to subp>agraph 7,a77ii74 ,su*  
me?ods & =mats--  7i7 %all1 9 ! case (  
su* me?od & =mat = mak+ public /&>d     
*>ges pursuant to subp>agraph 7,a77i71  
ensure t su* *>ges are made available 9 
a ma*9e-readable =mat 7or a successor   
te*nology specifi$ by ! ,secret>y72     
7ii7 may be simil> to any template made 
available by ! ,c5t]s = ,m$ic>e         
,m$icaid ,s]vices z ( ! date ( !        

enactm5t ( ?is subp>agraph2  7iii7 %all 
meet su* /&>ds z det]m9$ appropriate by 
! ,secret>y 9 ord] to ensure !          
accessibility & usability ( su* *>ges & 
prices2 &  7iv7 %all be updat$ z det]m9$
 appropriate by ! ,secret>y1 9          
consultation ) /akehold]s4  7#c7        
,monitor+ compliance ,! ,secret>y %all1 
?r\gh notice & comm5t rulemak+ & 9      
consultation ) ! ,inspector ,g5]al ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1   
e/abli% a process to monitor compliance 
) ?is subsection4 ,su* process %all     
ensure t ea* hospital's compliance ) ?is
 subsection is review$ n less frequ5tly 
?an once e #c ye>s4  7#d7 ,en=cem5t     
7,a7 ,9 g5]al ,9 ! case ( a hospital t  
fails to comply ) ! requirem5ts ( ?is   
subsection--  7i7 n lat] ?an #cj days   
aft] ! date on :i* ! ,secret>y det]m9es 
su* failure exi/s1 ! ,secret>y %all     
submit to su* hospital a notification ( 
su* det]m9ation 7:i* may include1 z     
det]m9$ appropriate by ! ,secret>y1 a   
reque/ = a corrective action plan to    

comply ) su* requirem5ts72 &  7ii7 9 !  
case ( a hospital t does n receive a    
reque/ = a corrective action plan z "p (
 a notification submitt$ by ! ,secret>y 
"u clause 7i7--  7,i7 ! ,secret>y %all1 
n lat] ?an #de days aft] su*            
notification is s5t1 det]m9e :e!r su*   
hospital is 9 compliance ) su*          
requirem5ts2 &  7,,ii7 if ! ,secret>y   
det]m9es "u subclause 7,i7 t su*        
hospital is n 9 compliance ) su*        
requirem5ts1 ! ,secret>y %all ei!r--    
7aa7 submit to su* hospital a reque/ = a
 corrective action plan to comply ) su* 
requirem5ts2 or  7bb7 if ! ,secret>y    
det]m9es t su* hospital has n tak5      
mean+ful actions to come into compliance
 s9ce su* notification 0 s5t1 impose a  
civil monet>y p5alty 9 accordance )     
subp>agraph 7,b74  7,b7 ,civil monet>y  
p5alty  7i7 ,9 g5]al ,9 addition to any 
o!r en=cem5t actions or p5alties t may  
apply "u ano!r provision ( law1 a       
hospital t has receiv$ a reque/ = a     
corrective action plan "u clause 7i7 or 

7ii7 ( subp>agraph 7,a7 & fails to      
comply ) ! requirem5ts ( ?is subsection 
by ! date t is #de days aft] su* reque/ 
is made1 & a hospital ) respect to :i* !
 ,secret>y has made a det]m9ation       
describ$ 9 clause 7ii77,,ii77bb7 ( su*  
subp>agraph1 %all be subject to a civil 
monet>y p5alty ( an am\nt specifi$ by ! 
,secret>y = ea* day 7beg9n+ ) ! day on  
:i* ! ,secret>y fir/ det]m9$ t su*      
hospital 0 n comply+ ) su* requirem5ts7 
dur+ :i* su* failure 0 ongo+4 ,su* am\nt
 %all n exce$-- 7,i7 9 ! case ( a       
hospital ) #cj or few] b$s1 #cjj p] day 
7or1 9 ! case ( su* a hospital t has be5
 noncompliant ) su* requirem5ts = a     
#a-ye> p]iod or long]1 beg9n+ ) ! fir/  
day foll[+ su* #a-ye> p]iod1 #djj p] b$ 
p] day72  7,,ii7 9 ! case ( a hospital )
 m ?an #cj b$s b few] ?an #aja b$s1     
#ab4ej p] b$ p] day 7or1 9 ! case ( su* 
a hospital t has be5 noncompliant ) su* 
requirem5ts = a #a-ye> p]iod or long]1  
beg9n+ ) ! fir/ day foll[+ su* #a-ye>   
p]iod1 #ae p] b$ p] day72  7,,iii7 9 !  

case ( a hospital ) m ?an #ajj b$s b    
few] ?an #bja b$s1 #ag4ej p] b$ p] day  
7or1 9 ! case ( su* a hospital t has be5
 noncompliant ) su* requirem5ts = a     
#a-ye> p]iod or long]1 beg9n+ ) ! fir/  
day foll[+ su* #a-ye> p]iod1 #bj p] b$  
p] day72  7,,iv7 9 ! case ( a hospital )
 m ?an #bjj b$s b few] ?an #eja b$s1 #bj
 p] b$ p] day 7or1 9 ! case ( su* a     
hospital t has be5 noncompliant ) su*   
requirem5ts = a #a-ye> p]iod or long]1  
beg9n+ ) ! fir/ day foll[+ su* #a-ye>   
p]iod1 #be p] b$ p] day72 &  7,v7 9 !   
case ( a hospital ) m ?an #ejj b$s1 #be 
p] b$ p] day 7or1 9 ! case ( su* a      
hospital t has be5 noncompliant ) su*   
requirem5ts = a #a-ye> p]iod or long]1  
beg9n+ ) ! fir/ day foll[+ su* #a-ye>   
p]iod1 #ce p] b$ p] day74  7ii7         
,increase au?ority ,9 apply+ ?is        
subp>agraph ) respect to violations     
occurr+ 9 #bjbg or a subsequ5t ye>1 !   
,secret>y may ?r\gh notice & comm5t     
rulemak+ increase-- 7,i7 ! limitation on
 ! p] day am\nt ( any p5alty applicable 

to a hospital "u clause 7i77,i72  7,,ii7
 ! limitations on ! p] b$ p] day am\nt (
 any p5alty applicable "u any (         
subclauses 7,,ii7 ?r\gh 7,v7 ( clause   
7i72 &  7,,iii7 ! am\nts specifi$ 9     
clause 7iii77,,ii74  7iii7 ,p]si/5t     
noncompliance  7,i7 ,9 g5]al ,9 ! case (
 a hospital 7o!r ?an a hospital ) #cj or
 few] b$s7 t ! ,secret>y has det]m9$ to 
be kn[+ly & willfully noncompliant ) !  
provisions ( ?is subsection two or m    
times dur+ a #a-ye> p]iod1 ! ,secret>y  
may increase any p5alty o!rwise         
applicable "u ?is subp>agraph by ! am\nt
 specifi$ 9 subclause 7,,ii7 ) respect  
to su* hospital & may require su*       
hospital to complete su* additional     
corrective actions plans z ! ,secret>y  
may specify4  7,,ii7 ,specifi$ am\nt ,= 
purposes ( subclause 7,i71 ! am\nt      
specifi$ 9 ?is subclause is1 ) respect  
to a hospital--  7aa7 ) m ?an #cj b$s b 
few] ?an #aja b$s1 an am\nt t is n less 
?an #ejj1jjj & n m ?an #a1jjj1jjj2  7bb7
 ) m ?an #ajj b$s b few] ?an #cja b$s1  

an am\nt t is great] ?an #a1jjj1jjj & n 
m ?an #b1jjj1jjj2  7cc7 ) m ?an #cjj b$s
 b few] ?an #eja b$s1 an am\nt t is     
great] ?an #b1jjj1jjj & n m ?an         
#d1jjj1jjj2 &  7dd7 ) m ?an #ejj b$s1 & 
am\nt t is n less ?an #e1jjj1jjj & n m  
?an #aj1jjj1jjj4  7iv7 ,au?ority to     
waive or r$uce p5alty  7,i7 ,9 g5]al    
,subject to subclause 7,,ii71 !         
,secret>y may waive any p5alty1 or r$uce
 any p5alty by n m ?an #ge p]c5t1       
o!rwise applicable "u ?is subp>agraph ) 
respect to a hospital locat$ 9 a rural  
or und]s]v$ area if ! ,secret>y c]tifies
 t imposition ( su* p5alty w\ld result 9
 an imm$iate ?reat to access to c>e =   
individuals 9 ! s]vice area ( su*       
hospital4  7,,ii7 ,limitation on        
application ,! ,secret>y may n elect to 
waive a p5alty "u subclause 7,i7 )      
respect to a hospital m ?an once 9 a    
#f-ye> p]iod & may n elect to r$uce su* 
a p5alty ) respect to su* a hospital m  
?an once 9 su* a p]iod4 ,no?+ 9 ! prec$+
 s5t5ce %all be con/ru$ z prohibit+ !   

,secret>y f bo? waiv+ & r$uc+ a p5alty )
 respect to a hospital dur+ a #f-ye>    
p]iod4  7v7 ,provision ( te*nical       
assi/ance ,! ,secret>y %all1 to ! ext5t 
practicable1 provide te*nical assi/ance 
relat+ to compliance ) ! provisions (   
?is section to hospitals reque/+ su*    
assi/ance4  7vi7 ,application ( c]ta9   
provisions ,! provisions ( section      
#aabh;,a 7o!r ?an subsections 7a7 & 7b7 
( su* section7 %all apply to a civil    
monet>y p5alty impos$ "u ?is subp>agraph
 9 ! same mann] z su* provisions apply  
to a civil monet>y p5alty impos$ "u     
subsection 7a7 ( su* section4  7vii7    
,nonduplication ( p5alties ,! ,secret>y 
may n subject a hospital to a civil     
monet>y p5alty "u ?is subp>agraph )     
respect to noncompliance ) ! provisions 
( ?is subsection = a p]iod if !         
,secret>y has impos$ a civil monet>y    
p5alty on su* hospital "u section       
#ahii;,c ( ! ,social ,security ,act =   
failure to comply ) ! provisions ( su*  
section = su* p]iod4  7,c7 ,publication 

( hospital price transp>5cy in=mation   
,beg9n+ on ,janu>y #a1 #bjbf1 !         
,secret>y %all make publicly available  
on ! public website ( ! ,c5t]s = ,m$ic>e
  ,m$icaid ,s]vices in=mation ) respect 
to compliance ) ! requirem5ts ( ?is     
subsection & en=cem5t activities        
und]tak5 by ! ,secret>y "u ?is          
subsection4 ,su* in=mation %all be      
updat$ 9 real "t & include--  7i7 !     
numb] ( reviews ( compliance ) ?is      
subsection und]tak5 by ! ,secret>y2     
7ii7 ! numb] ( notifications describ$ 9 
subp>agraph 7,a77i7 s5t by ! ,secret>y2 
7iii7 ! id5tity ( ea* hospital t 0 s5t  
su* a notification & a description ( !  
nature ( su* hospital's noncompliance ) 
?is subsection2  7iv7 ! am\nt ( any     
civil monet>y p5alty impos$ on su*      
hospital "u subp>agraph 7,b72  7v7 :e!r 
su* hospital subsequ5tly came into      
compliance ) ?is subsection2  7vi7 any  
waiv]s or r$uctions ( p5alties made     
pursuant to a c]tification by !         
,secret>y "u subp>agraph 7,b77iv71      

includ+--  7,i7 ! "n ( any hospital t   
receiv$ su* a waiv] or r$uction2  7,,ii7
 ! doll> am\nt ( ea* su* p5alty s waiv$ 
or r$uc$2 &  7,,iii7 ! rationale = !    
grant+ ( ea* su* waiv] or r$uction2 &   
7vii7 any o!r in=mation z det]m9$ by !  
,secret>y4  7#e7 ,ensur+ accessibility  
?r\gh implem5tation ,9 implem5t+ !      
am5dm5ts made by ?is section1 !         
,secret>y ( ,heal? & ,human ,s]vices    
%all ?r\gh rulemak+ ensure t a hospital 
submitt+ *>ges & in=mation pursuant to  
su* am5dm5ts takes reasonable /eps 7z   
specifi$ by ! ,secret>y7 to ensure !    
accessibility ( su* *>ges & in=mation to
 individuals ) limit$ ,engli% pr(ici5cy4
 ,su* /eps may include ! hospital's     
provision ( int]pretation s]vices or !  
hospital's provision ( translations (   
*>ges & in=mation4  7#f7 ,def9itions ,= 
purposes ( ?is subsection3  7,a7        
,disc\nt$ ca% price ,! t]m disc\nt$ ca% 
price means ! *>ge t applies to an      
individual :o pays ca%1 or ca%          
equival5t1 = a hospital-furni%$ item or 

s]vice4  7,b7 ,f$]al heal? c>e program  
,! t]m ,f$]al heal? c>e program has !   
mean+ giv5 su* t]m 9 section #aabh;,b ( 
! ,social ,security ,act4  7,c7 ,gross  
*>ge ,! t]m gross *>ge means ! *>ge = an
 individual item or s]vice t is reflect$
 on a hospital's *>gema/]1 abs5t any    
disc\nts4  7,d7 ,pay]-specific negotiat$
 *>ge ,! t]m pay]-specific negotiat$    
*>ge means ! *>ge t a hospital has      
negotiat$ ) a ?ird p>ty pay] = an item  
or s]vice4  7,e7 ,%oppable s]vice ,! t]m
 %oppable s]vice means a s]vice t c be  
s*$ul$ by a heal? c>e consum] 9 advance 
& includes all ancill>y items & s]vices 
cu/om>ily furni%$ z "p ( su* s]vice4    
7,f7 ,?ird p>ty pay] ,! t]m ?ird p>ty   
pay] means an entity t is1 by /atute1   
contract1 or agreem5t1 legally          
responsible = paym5t ( a claim = a heal?
 c>e item or s]vice4  4  7#b7 ,con=m+   
am5dm5ts ,section #bgah ( ! ,public     
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#ah7 is am5d$-- 7,a7 9          
subsection 7b77#c71 by ins]t+ 7o!r ?an !

 provisions ( subsection 7f77 aft] ?is  
section2 &  7,b7 9 subsection 7e71 by   
add+ at ! end ! foll[+ new s5t5ce3 ,!   
prec$+ provisions ( ?is subsection %all 
n apply beg9n+ on ,janu>y #a1 #bjbf44   
7#c7 ,effective date ,! am5dm5ts made by
 ?is subsection %all apply beg9n+       
,janu>y #a1 #bjbf4  7c7 ,accessibility  
?r\gh implem5tation ,9 implem5t+ !      
am5dm5ts made by ?is section1 !         
,secret>y ( ,heal? & ,human ,s]vices    
%all ?r\gh rulemak+ ensure t a hospital 
submitt+ *>ges & in=mation pursuant to  
su* am5dm5ts takes reasonable /eps 7z   
specifi$ by ! ,secret>y7 to ensure !    
accessibility ( su* *>ges & in=mation to
 individuals ) limit$ ,engli% pr(ici5cy4
 ,su* /eps may include ! hospital's     
provision ( int]pretation s]vices or !  
hospital's provision ( translations (   
*>ges & in=mation4  #ajb4 ,cl9ical      
diagno/ic laboratory te/ price          
transp>5cy ,section #ahdf ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #aciew-#b7
 is am5d$--  7#a7 9 ! head]1 by ins]t+ &

 additional requirem5ts aft] sanctions2 
&  7#b7 by add+ at ! end ! foll[+ new   
subsection3  7c7 ,price transp>5cy      
requirem5t  7#a7 ,9 g5]al ,beg9n+       
,janu>y #a1 #bjbf1 any applicable       
laboratory t receives paym5t "u ?is     
title = furni%+ any specifi$ cl9ical    
diagno/ic laboratory te/ "u ?is title   
%all-- 7,a7 make publicly available on  
an int]net website ! in=mation describ$ 
9 p>agraph 7#b7 ) respect to ea* su*    
specifi$ cl9ical diagno/ic laboratory   
te/ t su* laboratory s furni%es2 &  7,b7
 ensure t su* in=mation is updat$ n less
 frequ5tly ?an annually4  7#b7          
,in=mation describ$ ,= purposes (       
p>agraph 7#a71 ! in=mation describ$ 9   
?is p>agraph is1 ) respect to an        
applicable laboratory & a specifi$      
cl9ical diagno/ic laboratory te/1 !     
foll[+3  7,a7 ,! disc\nt$ ca% price =   
su* te/ 7or1 if no su* price exi/s1 !   
gross *>ge = su* te/74  7,b7 ,!         
deid5tifi$ m9imum pay]-specific         
negotiat$ *>ge betwe5 su* laboratory &  

any ?ird p>ty pay] = su* te/4  7,c7 ,!  
deid5tifi$ maximum pay]-specific        
negotiat$ *>ge betwe5 su* laboratory &  
any ?ird p>ty pay] = su* te/4  7#c7     
,uni=m me?od & =mat ,n lat] ?an ,janu>y 
#a1 #bjbf1 ! ,secret>y %all e/abli% a   
/&>d1 uni=m me?od & =mat = applicable   
laboratories to use 9 compil+ & mak+    
public in=mation pursuant to p>agraph   
7#a74 ,su* me?od & =mat--  7,a7 may be  
simil> to any template made available by
 ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices  
7z describ$ 9 section                   
#ahii;,c7a77#b77;,c77ii772  7,b7 %all   
meet su* /&>ds z det]m9$ appropriate by 
! ,secret>y 9 ord] to ensure !          
accessibility & usability ( su*         
in=mation2 &  7,c7 %all be updat$ z     
det]m9$ appropriate by ! ,secret>y1 9   
consultation ) /akehold]s4  7#d7        
,inclusion ( ancill>y s]vices ,any price
 or rate = a specifi$ cl9ical diagno/ic 
laboratory te/ available to be furni%$  
by an applicable laboratory made        
publicly available 9 accordance )       

p>agraph 7#a7 %all include ! price or   
rate 7z applicable7 = any ancill>y item 
or s]vice 7su* z specim5 collection     
s]vices7 t w\ld normally be furni%$ by  
su* laboratory z "p ( su* te/1 z        
specifi$ by ! ,secret>y4  7#e7 ,en=cem5t
  7,a7 ,9 g5]al ,9 ! case t ! ,secret>y 
det]m9es t an applicable laboratory is n
 9 compliance ) p>agraph 7#a7-- 7i7 n   
lat] ?an #cj days aft] su* det]m9ation1 
! ,secret>y %all notify su* laboratory (
 su* det]m9ation2 &  7ii7 if su*        
laboratory cont9ues to fail to comply ) 
su* p>agraph aft] ! date t is #ij days  
aft] su* notification is s5t1 !         
,secret>y may impose a civil monet>y    
p5alty 9 an am\nt n to exce$ #cjj = ea* 
7beg9n+ ) ! day on :i* ! ,secret>y fir/ 
det]m9$ t su* laboratory 0 fail+ to     
comply ) su* p>agraph7 dur+ :i* su*     
failure is ongo+4  7,b7 ,increase       
au?ority ,9 apply+ ?is p>agraph )       
respect to violations occurr+ 9 #bjbg or
 a subsequ5t ye>1 ! ,secret>y may ?r\gh 
notice & comm5t rulemak+ increase ! p]  

day limitation on civil monet>y p5alties
 "u subp>agraph 7,a77ii74  7,c7         
,application ( c]ta9 provisions ,!      
provisions ( section #aabh;,a 7o!r ?an  
subsections 7a7 & 7b7 ( su* section7    
%all apply to a civil monet>y p5alty    
impos$ "u ?is p>agraph 9 ! same mann] z 
su* provisions apply to a civil monet>y 
p5alty impos$ "u subsection 7a7 ( su*   
section4  7#f7 ,provision ( te*nical    
assi/ance ,! ,secret>y %all1 to ! ext5t 
practicable1 provide te*nical assi/ance 
relat+ to compliance ) ! provisions (   
?is subsection to applicable            
laboratories reque/+ su* assi/ance4     
7#g7 ,def9itions ,9 ?is subsection3 7,a7
 ,applicable laboratory ,! t]m          
applicable laboratory has ! mean+ giv5  
su* t]m 9 section #dad4ejb1 ( title #db1
 ,code ( ,f$]al ,regulations 7or a      
successor regulation71 except t su* t]m 
does n include a laboratory ) respect to
 :i* /&>d *>ges & prices = specifi$     
cl9ical diagno/ic laboratory te/s       
furni%$ by su* laboratory are made      

available by a hospital pursuant to     
section #ahii;,c or section #bgah7;f7 ( 
! ,public ,heal? ,s]vice ,act4  7,b7    
,disc\nt$ ca% price ,! t]m disc\nt$ ca% 
price means ! *>ge t applies to an      
individual :o pays ca%1 or ca%          
equival5t1 = an item or s]vice4  7,c7   
,gross *>ge ,! t]m gross *>ge means !   
*>ge = an individual item or s]vice t is
 reflect$ on an applicable laboratory's 
*>gema/]1 abs5t any disc\nts4  7,d7     
,pay]-specific negotiat$ *>ge ,! t]m    
pay]-specific negotiat$ *>ge means !    
*>ge t an applicable laboratory has     
negotiat$ ) a ?ird p>ty pay] = an item  
or s]vice4  7,e7 ,specifi$ cl9ical      
diagno/ic laboratory te/ ! t]m specifi$ 
cl9ical diagno/ic laboratory te/ means a
 cl9ical diagno/ic laboratory te/ t is  
includ$ on ! li/ ( %oppable s]vices     
specifi$ by ! ,c5t]s = ,m$ic>e  ,m$icaid
 ,s]vices 7z describ$ 9 section         
#ahii;,c7a77#b77;,a77ii77,i771 o!r ?an  
su* a te/ t is only available to be     
furni%$ by a s+le provid] ( s]vices or  

suppli]4  7,f7 ,?ird p>ty pay] ,! t]m   
?ird p>ty pay] means an entity t is1 by 
/atute1 contract1 or agreem5t1 legally  
responsible = paym5t ( a claim = a heal?
 c>e item or s]vice4  4  #ajc4 ,imag+   
price transp>5cy ,section #ahii;,c ( !  
,social ,security ,act1 z add$ by       
section #aja1 is am5d$--  7#a7 by       
r$esignat+ subsection 7b7 z subsection  
7c72  7#b7 by ins]t+ aft] subsection 7a7
 ! foll[+ new subsection3  7b7 ,imag+   
s]vices price transp>5cy  7#a7 ,9 g5]al 
,beg9n+ ,janu>y #a1 #bjbh1 ea* provid] (
 s]vices & suppli] t receives paym5t "u 
?is title = furni%+ a specifi$ imag+    
s]vice1 o!r ?an su* a provid] or suppli]
 ) respect to :i* /&>d *>ges & prices = 
su* s]vices furni%$ by su* provid] or   
suppli] are made available by a hospital
 pursuant to section #ahii;,c or section
 #bgah7;f7 ( ! ,public ,heal? ,s]vice   
,act1 %all-- 7,a7 make publicly         
available 79 accordance ) p>agraph 7#c77
 on an int]net website ! in=mation      
describ$ 9 p>agraph 7#b7 ) respect to   

ea* su* s]vice t su* provid] ( s]vices  
or suppli] furni%es2 &  7,b7 ensure t   
su* in=mation is updat$ n less frequ5tly
 ?an annually4  7#b7 ,in=mation describ$
 ,= purposes ( p>agraph 7#a71 !         
in=mation describ$ 9 ?is p>agraph is1 ) 
respect to a provid] ( s]vices or       
suppli] & a specifi$ imag+ s]vice1 !    
foll[+3  7,a7 ,! disc\nt$ ca% price =   
su* s]vice 7or1 if no su* price exi/s1 !
 gross *>ge = su* s]vice74  7,b7 ,if    
requir$ by ! ,secret>y1 ! deid5tifi$    
m9imum pay]-specific negotiat$ *>ge =   
su* s]vice & ! deid5tifi$ maximum       
pay]-specific negotiat$ *>ge = su*      
s]vice4  7#c7 ,uni=m me?od & =mat ,n    
lat] ?an ,janu>y #a1 #bjbh1 ! ,secret>y 
%all e/abli% a /&>d1 uni=m me?od & =mat 
= provid]s ( s]vices & suppli]s to use 9
 mak+ public in=mation describ$ 9       
p>agraph 7#b74 ,any su* me?od & =mat--  
7,a7 may be simil> to any template made 
available by ! ,c5t]s = ,m$ic>e         
,m$icaid ,s]vices 7z describ$ 9 section 
#ahii;,c7a77#b77;,c77ii772  7,b7 %all   

meet su* /&>ds z det]m9$ appropriate by 
! ,secret>y 9 ord] to ensure !          
accessibility & usability ( su*         
in=mation2 &  7,c7 %all be updat$ z     
det]m9$ appropriate by ! ,secret>y1 9   
consultation ) /akehold]s4  7#d7        
,monitor+ compliance ,! ,secret>y %all1 
?r\gh notice & comm5t rulemak+ & 9      
consultation ) ! ,inspector ,g5]al ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1   
e/abli% a process to monitor compliance 
) ?is subsection4  7#e7 ,en=cem5t  7,a7 
,9 g5]al ,9 ! case t ! ,secret>y        
det]m9es t a provid] ( s]vices or       
suppli] is n 9 compliance ) p>agraph    
7#a7--  7i7 n lat] ?an #cj days aft] su*
 det]m9ation1 ! ,secret>y %all notify   
su* provid] or suppli] ( su*            
det]m9ation2  7ii7 ^u reque/ ( !        
,secret>y1 su* provid] or suppli] %all  
submit to ! ,secret>y1 n lat] ?an #de   
days aft] ! date ( su* reque/1 a        
corrective action plan to comply ) su*  
p>agraph2 &  7iii7 if su* provid] or    
suppli] cont9ues to fail to comply ) su*

 p>agraph aft] ! date t is #ij days aft]
 su* notification is s5t 7or1 9 ! case (
 su* a provid] or suppli] t has submitt$
 a corrective action plan describ$ 9    
clause 7ii7 9 response to a reque/ s    
describ$1 aft] ! date t is #ij days aft]
 su* submission71 ! ,secret>y may impose
 a civil monet>y p5alty 9 an am\nt n to 
exce$ #cjj = ea* day 7beg9n+ ) ! day on 
:i* ! ,secret>y fir/ det]m9$ t su*      
provid] or suppli] 0 fail+ to comply )  
su* p>agraph7 dur+ :i* su* failure to   
comply or failure to submit is ongo+4   
7,b7 ,increase au?ority ,9 apply+ ?is   
p>agraph ) respect to violations occurr+
 9 #bjbi or a subsequ5t ye>1 ! ,secret>y
 may ?r\gh notice & comm5t rulemak+     
increase ! am\nt ( ! civil monet>y      
p5alty "u subp>agraph 7,a77iii74  7,c7  
,application ( c]ta9 provisions ,!      
provisions ( section #aabh;,a 7o!r ?an  
subsections 7a7 & 7b7 ( su* section7    
%all apply to a civil monet>y p5alty    
impos$ "u ?is p>agraph 9 ! same mann] z 
su* provisions apply to a civil monet>y 

p5alty impos$ "u subsection 7a7 ( su*   
section4  7,d7 ,au?ority to waive or    
r$uce p5alty  7i7 ,9 g5]al ,subject to  
clause 7ii71 ! ,secret>y may waive or   
r$uce any p5alty o!rwise applicable )   
respect to a provid] ( s]vices or       
suppli] "u ?is subp>agraph if !         
,secret>y c]tifies t imposition ( su*   
p5alty w\ld result 9 an imm$iate ?reat  
to access to c>e = individuals 9 !      
s]vice area ( su* provid] or suppli]4   
7ii7 ,limitation ,! ,secret>y may n     
elect to waive or r$uce a p5alty "u     
clause 7i7 ) respect to a specific      
provid] ( s]vices or suppli] m ?an #c   
times4  7,e7 ,provision ( te*nical      
assi/ance ,! ,secret>y %all1 to ! ext5t 
practicable1 provide te*nical assi/ance 
relat+ to compliance ) ! provisions (   
?is subsection to provid]s ( s]vices &  
suppli]s reque/+ su* assi/ance4  7,f7   
,cl>ification ( nonapplicability ( o!r  
en=cem5t provisions ,not)/&+ any o!r    
provision ( ?is title1 ?is p>agraph %all
 be ! sole means ( en=c+ ! provisions ( 

?is subsection4  2 &  7#c7 9 subsection 
7c71 z s r$esignat$ by p>agraph 7#a7--  
7,a7 by r$esignat+ p>agraph 7#h7 z      
p>agraph 7#i72 &  7,b7 by ins]t+ aft]   
p>agraph 7#g7 ! foll[+ new p>agraph3    
7#h7 ,specifi$ imag+ s]vice ! t]m       
specifi$ imag+ s]vice means an imag+    
s]vice t is a ,c5t]s = ,m$ic>e  ,m$icaid
 ,s]vices-specifi$ %oppable s]vice 7z   
describ$ 9 subsection                   
7a77#b77;,a77ii77,i774  4  #ajd4        
,ambulatory surgical c5t] price         
transp>5cy ,section #ahcd ( ! ,social   
,security ,act 7#db ,u4,s4,c4 #aciem7 is
 am5d$ by add+ at ! end ! foll[+ new    
subsection3  7aa7 ,ambulatory surgical  
c5t] price transp>5cy  7#a7 ,9 g5]al    
,beg9n+ ,janu>y #a1 #bjbf1 ea*          
ambulatory surgical c5t] t receives     
paym5t "u ?is title = furni%+ items &   
s]vices %all comply ) ! price transp>5cy
 requirem5t describ$ 9 p>agraph 7#b74   
7#b7 ,requirem5t describ$  7,a7 ,9 g5]al
 ,= purposes ( p>agraph 7#a71 ! price   
transp>5cy requirem5t describ$ 9 ?is    

subsection is1 ) respect to an          
ambulatory surgical c5t]1 t su* surgical
 c5t] 9 accordance ) a me?od & =mat     
e/abli%$ by ! ,secret>y "u subp>agraph  
7,c71 compile & make public 7)\t        
subscription & free ( *>ge71 = ea* ye>--
  7i7 all ( ! ambulatory surgical c5t]'s
 /&>d *>ges 7includ+ ! in=mation        
describ$ 9 subp>agraph 7,b77 = ea* item 
& s]vice furni%$ by su* surgical c5t]2  
7ii7 in=mation on ! ambulatory surgical 
c5t]'s prices 7includ+ ! in=mation      
describ$ 9 subp>agraph 7,b77 = z _m ( ! 
,c5t]s = ,m$ic>e  ,m$icaid              
,s]vices-specifi$ %oppable s]vices t are
 furni%$ by su* surgical c5t]1 & z _m   
additional ambulatory surgical          
c5t]-select$ %oppable s]vices 7or all   
su* additional s]vices1 if su* surgical 
c5t] furni%es few] ?an #cjj %oppable    
s]vices7 z may be necess>y = a comb9$   
total ( at lea/ #cjj %oppable s]vices2 &
  7iii7 ) respect to ea* ,c5t]s =       
,m$ic>e  ,m$icaid ,s]vices-specifi$     
%oppable s]vice t is n furni%$ by !     

ambulatory surgical c5t]1 an indication 
t su* s]vice is n s furni%$4  7,b7      
,in=mation describ$ ,= purposes (       
subp>agraph 7,a71 ! in=mation describ$ 9
 ?is subp>agraph is1 ) respect to /&>d  
*>ges & prices 7z applicable7 made      
public by an ambulatory surgical c5t]1 !
 foll[+3  7i7 ,a pla9 language          
description ( ea* item or s]vice1       
accompani$ by1 z applicable1 ! ,heal?c>e
 ,common ,proc$ure ,cod+ ,sy/em code1 ! 
diagnosis-relat$ gr\p1 ! national drug  
code1 or o!r id5tifi] us$ or approv$ by 
! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices4  
7ii7 ,! gross *>ge1 z applicable1       
express$ z a doll> am\nt1 = ea* su* item
 or s]vice4  7iii7 ,! disc\nt$ ca%      
price1 z applicable1 express$ z a doll> 
am\nt1 = ea* su* item or s]vice 7or1 9 !
 case no disc\nt$ ca% price is available
 = an item or s]vice1 ! m$ian ca% price 
*>g$ to self-pay individuals = su* item 
or s]vice = ! previ\s ?ree ye>s1        
express$ z a doll> am\nt74  7iv7 ,!     
curr5t pay]-specific negotiat$ *>ges1   

cle>ly associat$ ) ! "n ( ! ?ird p>ty   
pay] & plan & express$ z a doll> am\nt1 
t applies to ea* su* item or s]vice4    
7v7 ,! de-id5tifi$ maximum & m9imum     
negotiat$ *>ges1 z applicable1 = ea* su*
 item or s]vice4  7vi7 ,any o!r         
additional in=mation ! ,secret>y may    
require = ! purpose ( improv+ ! accuracy
 (1 or enabl+ consum]s to easily und]/& 
& comp>e1 /&>d *>ges & prices = an item 
or s]vice1 except in=mation t is        
duplicative ( any o!r report+ requirem5t
 "u ?is subsection4  7,c7 ,uni=m me?od &
 =mat ,n lat] ?an ,janu>y #a1 #bjbf1 !  
,secret>y %all e/abli% a /&>d1 uni=m    
me?od & =mat = ambulatory surgical c5t]s
 to use 9 mak+ public /&>d *>ges & a    
/&>d1 uni=m me?od & =mat = su* c5t]s to 
use 9 mak+ public prices pursuant to    
subp>agraph 7,a74 ,any su* me?od &      
=mat-- 7i7 %all1 9 ! case ( su* *>ges   
made public by an ambulatory surgical   
c5t]1 ensure t su* *>ges are made       
available 9 a ma*9e-readable =mat 7or   
successor te*nology72  7ii7 may be      

simil> to any template made available by
 ! ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices z
 ( ! date ( ! enactm5t ( ?is p>agraph2  
7iii7 %all meet su* /&>ds z det]m9$     
appropriate by ! ,secret>y 9 ord] to    
ensure ! accessibility & usability ( su*
 *>ges & prices2 &  7iv7 %all be updat$ 
z det]m9$ appropriate by ! ,secret>y1 9 
consultation ) /akehold]s4  7#c7        
,monitor+ compliance ,! ,secret>y %all1 
?r\gh notice & comm5t rulemak+ & 9      
consultation ) ! ,inspector ,g5]al ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1   
e/abli% a process to monitor compliance 
) ?is subsection4 ,su* process %all     
ensure t ea* ambulatory surgical c5t]'s 
compliance ) ?is subsection is review$ n
 less frequ5tly ?an once e #c ye>s4     
7#d7 ,en=cem5t  7,a7 ,9 g5]al ,9 ! case 
( an ambulatory surgical c5t] t fails to
 comply ) ! requirem5ts ( ?is           
subsection-- 7i7 ! ,secret>y %all notify
 su* ambulatory surgical c5t] ( su*     
failure n lat] ?an #cj days aft] ! date 
on :i* ! ,secret>y det]m9es su* failure 

exi/s2 &  7ii7 ^u reque/ ( ! ,secret>y1 
! ambulatory surgical c5t] %all submit  
to ! ,secret>y1 n lat] ?an #de days aft]
 ! date ( su* reque/1 a corrective      
action plan to comply ) su* requirem5ts4
  7,b7 ,civil monet>y p5alty  7i7 ,9    
g5]al ,9 addition to any o!r en=cem5t   
actions or p5alties t may apply "u ano!r
 provision ( law1 an ambulatory surgical
 c5t] t has receiv$ a notification "u   
subp>agraph 7,a77i7 & fails to comply ) 
! requirem5ts ( ?is subsection by ! date
 t is #ij days aft] su* notification    
7or1 9 ! case ( an ambulatory surgical  
c5t] t has submitt$ a corrective action 
plan describ$ 9 subp>agraph 7,a77ii7 9  
response to a reque/ s describ$1 by !   
date t is #ij days aft] su* submission7 
%all be subject to a civil monet>y      
p5alty ( an am\nt specifi$ by !         
,secret>y = ea* subsequ5t day dur+ :i*  
su* failure is ongo+ 7n to exce$ #cjj p]
 day74  7ii7 ,increase au?ority ,9      
apply+ ?is subp>agraph ) respect to     
violations occurr+ 9 #bjbg or a         

subsequ5t ye>1 ! ,secret>y may ?r\gh    
notice & comm5t rulemak+ increase !     
limitation on ! p] day am\nt ( any      
p5alty applicable to an ambulatory      
surgical c5t] "u clause 7i74  7iii7     
,application ( c]ta9 provisions ,!      
provisions ( section #aabh;,a 7o!r ?an  
subsections 7a7 & 7b7 ( su* section7    
%all apply to a civil monet>y p5alty    
impos$ "u ?is subp>agraph 9 ! same mann]
 z su* provisions apply to a civil      
monet>y p5alty impos$ "u subsection 7a7 
( su* section4  7iv7 ,au?ority to waive 
or r$uce p5alty  7,i7 ,9 g5]al ,subject 
to subclause 7,,ii71 ! ,secret>y may    
waive any p5alty1 or r$uce any p5alty by
 n m ?an #ge p]c5t1 o!rwise applicable  
"u ?is subp>agraph ) respect to an      
ambulatory surgical c5t] locat$ 9 a     
rural or und]s]v$ area if ! ,secret>y   
c]tifies t imposition ( su* p5alty w\ld 
result 9 an imm$iate ?reat to access to 
c>e = individuals 9 ! s]vice area ( su* 
surgical c5t]4  7,,ii7 ,limitation on   
application ,! ,secret>y may n elect to 

waive a p5alty "u subclause 7,i7 )      
respect to an ambulatory surgical c5t] m
 ?an once 9 a #f-ye> p]iod & may n elect
 to r$uce su* a p5alty ) respect to su* 
a surgical c5t] m ?an once 9 su* a      
p]iod4 ,no?+ 9 ! prec$+ s5t5ce %all be  
con/ru$ z prohibit+ ! ,secret>y f bo?   
waiv+ & r$uc+ a p5alty ) respect to an  
ambulatory surgical c5t] dur+ a #f-ye>  
p]iod4  7#e7 ,def9itions ,= purposes (  
?is section3 7,a7 ,disc\nt$ ca% price ,!
 t]m disc\nt$ ca% price means ! *>ge t  
applies to an individual :o pays ca%1 or
 ca% equival5t1 = a item or s]vice      
furni%$ by an ambulatory surgical c5t]4 
7,b7 ,f$]al heal? c>e program ,! t]m    
,f$]al heal? c>e program has ! mean+    
giv5 su* t]m 9 section #aabh;,b4  7,c7  
,gross *>ge ,! t]m gross *>ge means !   
*>ge = an individual item or s]vice t is
 reflect$ on an ambulatory surgical     
c5t]'s *>gema/]1 abs5t any disc\nts4    
7,d7 ,gr\p heal? plan2 gr\p heal?       
insurance cov]age2 individual heal?     
insurance cov]age ,! t]ms gr\p heal?    

plan1 gr\p heal? insurance cov]age1 &   
individual heal? insurance cov]age h !  
mean+ giv5 su* t]ms 9 section #bgia ( ! 
,public ,heal? ,s]vice ,act4  7,e7      
,pay]-specific negotiat$ *>ge ,! t]m    
pay]-specific negotiat$ *>ge means !    
*>ge t an ambulatory surgical c5t] has  
negotiat$ ) a ?ird p>ty pay] = an item  
or s]vice4  7,f7 ,%oppable s]vice ,! t]m
 %oppable s]vice means a s]vice t c be  
s*$ul$ by a heal? c>e consum] 9 advance 
& includes all ancill>y items & s]vices 
cu/om>ily furni%$ z "p ( su* s]vice4    
7,g7 ,?ird p>ty pay] ,! t]m ?ird p>ty   
pay] means an entity t is1 by /atute1   
contract1 or agreem5t1 legally          
responsible = paym5t ( a claim = a heal?
 c>e item or s]vice4  4  #aje4 ,heal?   
cov]age price transp>5cy  7a7 ,price    
transp>5cy requirem5ts  7#a7 ,,irc  7,a7
 ,9 g5]al ,section #ihai ( ! ,int]nal   
,rev5ue ,code ( #aihf is am5d$ to read z
 foll[s3  #ihai4 ,transp>5cy 9 cov]age  
7a7 ,co/-%>+ transp>5cy  7#a7 ,9 g5]al  
,= plan ye>s beg9n+ on or aft] ,janu>y  

#a1 #bjbf1 a gr\p heal? plan %all p]mit 
a p>ticipant or b5efici>y to le>n !     
am\nt ( co/-%>+ 7includ+ d$uctibles1    
copaym5ts1 & co9surance7 "u ! p>ticipant
 or b5efici>y's plan t ! p>ticipant or  
b5efici>y w\ld be responsible = pay+ )  
respect to ! furni%+ ( a specific item  
or s]vice by a provid] 9 a timely mann] 
^u ! reque/ ( ! p>ticipant or b5efici>y4
 ,at a m9imum1 su* in=mation %all       
include ! in=mation specifi$ 9 p>agraph 
7#b7 & %all be made available to su*    
p>ticipant or b5efici>y ?r\gh a         
self-s]vice tool t meets ! requirem5ts (
 p>agraph 7#c7 or1 at ! option ( su*    
p>ticipant or b5efici>y1 ?r\gh a pap]   
disclosure or phone or o!r electronic   
disclosure 7z select$ by su* p>ticipant 
or b5efici>y & provid$ at no co/ to su* 
p>ticipant or b5efici>y7 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 7c77 = su* item or   
s]vice4  7,b7 ,if su* provid] is n a    
p>ticipat+ provid] ) respect to su* item
 or s]vice1 ! maximum all[$ am\nt or o!r
 doll> am\nt t su* plan or cov]age w    
recognize z paym5t = su* item or s]vice1
 along ) a notice t su* p>ticipant or   
b5efici>y may be liable = additional    
*>ges4  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+ ! maximum   
all[$ am\nt or o!r doll> am\nt describ$ 
9 su* subp>agraph74  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 ,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,f7 ,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,g7 ,any %>$ sav+s 7su* z any   
cr$it1 paym5t1 or o!r b5efit provid$ by 
su* plan7 available to ! p>ticipant or  
b5efici>y ) respect to su* item or      
s]vice furni%$ by su* provid] kn[n at ! 
"t su* reque/ is made4  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 website 7or successor    
te*nology specifi$ by ! ,secret>y72     
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 timely &      
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 or  7ii7 all provid]s t are 
p>ticipat+ provid]s ) respect to su*    
item or s]vice2  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]vice2 & 
7,f7 meets any o!r requirem5t det]m9$   
appropriate by ! ,secret>y to ensure !  
accessibility & usability ( in=mation   
provid$ ?r\gh su* tool4  ,! ,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 simil> items & s]vices4  7b7 ,rate & 
paym5t in=mation  7#a7 ,9 g5]al ,= plan 
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbf1 ea* gr\p heal? plan 7o!r ?an a   
gr&fa!r$ heal? plan 7z def9$ 9 section  
#abea7;e7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act77 %all1 = ea* mon?1 
n lat] ?an ! t5? day ( su* mon?1 make   
available to ! public ! rate & paym5t   
in=mation describ$ 9 p>agraph 7#b7 9    
accordance ) p>agraph 7#c74  7#b7 ,rate 
& paym5t in=mation describ$ ,= purposes 
( p>agraph 7#a71 ! rate & paym5t        
in=mation describ$ 9 ?is p>agraph 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 
7express$ z a doll> am\nt7 9 effect z ( 
! date on :i* su* in=mation is made     
public ) ea* provid] t is a p>ticipat+  
provid] ) respect to su* item or s]vice4

  7,b7 ,) respect to ea* drug 7id5tifi$ 
by national drug code7 = :i* b5efits are
 available "u su* plan-- 7i7 ! 9-network
 rate 7express$ z a doll> am\nt7 9      
effect z ( ! fir/ day ( ! mon? 9 :i* su*
 in=mation is made public ) ea* provid] 
t is a p>ticipat+ provid] ) respect to  
su* drug2 &  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 ( publication to
 ea* provid] t 0 a p>ticipat+ provid] ) 
respect to su* drug1 brok5 d[n by ea*   
su* provid]1 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*  
plan4  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]4  7#c7 ,mann] ( publication     
,rate & paym5t in=mation requir$ to be  
made available "u ?is subsection %all be
 s made available 9 doll> am\nts ?r\gh  
sep>ate ma*9e-readable files 7& any     
successor te*nology1 su* z application  
program int]face te*nology1 det]m9$     
appropriate by ! ,secret>y7 correspond+ 
to ! in=mation describ$ 9 ea* (         
subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 
7#b7 t meet su* requirem5ts z specifi$  
by ! ,secret>y ?r\gh subregulatory      
guidance4 ,su* requirem5ts %all ensure t
 su* files are limit$ to an appropriate 
size1 d n include disclosure (          
unnecess>y duplicative in=mation conta9$
 9 o!r files made available "u ?is      
subsection1 are made available 9 a      
widely available =mat ?r\gh a publicly  
available website 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$5tials4  7#d7 ,us]       
in/ructions ,ea* gr\p heal? plan %all   
make available to ! public in/ructions  
writt5 9 pla9 language expla9+ h[       
individuals may se>* = in=mation        
describ$ 9 p>agraph 7#b7 9 files        
submitt$ 9 accordance ) p>agraph 7#c74  
,! ,secret>y %all develop & publi% ?r\gh
 subregulatory guidance a template t su*
 a plan may use 9 develop+ in/ructions =
 purposes ( ! prec$+ s5t5ce4  7#e7      
,summ>y ,= ea* plan ye> beg9n+ on or    
aft] ,janu>y #a1 #bjbf1 ea* gr\p heal?  
plan %all make public a data file1 9 a  
mann] t ensures t su* file may be easily
 d[nload$ & read by /&>d spread%eet     
s(tw>e & t meets su* requirem5ts z      
e/abli%$ by ! ,secret>y1 conta9+ a      
summ>y ( all rate & paym5t in=mation    
made public by su* plan ) respect to su*
 plan dur+ su* plan ye>4 ,su* file %all 
include ! foll[+3 7,a7 ,! mean1 m$ian1 &
 int]qu>tile range ( ! 9-network rate1 &
 ! am\nt all[$ = an item or s]vice :5 n 
furni%$ by a p>ticipat+ provid]1 9      

effect z ( ! fir/ day ( su* plan ye> =  
ea* item or s]vice 7id5tifi$ by pay]    
id5tifi] approv$ or us$ by ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices7 = :i*       
b5efits are available "u ! plan1 brok5  
d[n by ! type ( provid] furni%+ ! item  
or s]vice & by ! geographic area 9 :i*  
su* item or s]vice is furni%$4  7,b7    
,tr5ds 9 paym5t rates = su* items &     
s]vices ov] su* plan ye>1 includ+ an    
id5tification ( in/ances 9 :i* su* rates
 h increas$1 decreas$1 or rema9$ ! same4
  7,c7 ,! "n ( su* plan1 a description (
 ! type ( network ( p>ticipat+ provid]s 
us$ by su* plan1 & a description ( :e!r 
su* plan is self-insur$ or fully-insur$4
  7,d7 ,= ea* item or s]vice :i* is paid
 z "p ( a bundl$ rate-- 7i7 a           
description ( ! =mulae1 pric+           
me?odologies1 or o!r in=mation us$ to   
calculate ! paym5t rate = su* bundle2 & 
7ii7 a li/ ( ! items & s]vices includ$ 9
 su* bundle4  7,e7 ,! p]c5tage ( items &
 s]vices t are paid = on a fee-=-s]vice 
basis & ! p]c5tage ( items & s]vices t  

are paid = z "p ( a bundl$ rate1        
capitat$ paym5t rate1 or o!r alt]native 
paym5t model4  7#f7 ,atte/ation ,ea*    
gr\p heal? plan %all po/1 along ) rate &
 paym5t in=mation made public by su*    
plan1 an atte/ation t su* in=mation is  
complete & accurate4  7c7 ,accessibility
 ,a gr\p heal? plan %all take reasonable
 /eps 7z specifi$ by ! ,secret>y7 to    
ensure t in=mation provid$ 9 response to
 a reque/ describ$ 9 subsection 7a71 &  
rate & paym5t in=mation made public "u  
subsection 7b71 is provid$ 9 pla91      
easily und]/&able language & t          
int]pretation1 translations1 & assi/ive 
s]vices are provid$ to ^? ) limit$      
,engli% pr(ici5cy & ^? ) disabilities4  
7d7 ,def9itions ,9 ?is section3 7#a7    
,p>ticipat+ provid] ,! t]m p>ticipat+   
provid] means1 ) respect to an item or  
s]vice & a gr\p heal? plan1 a physician 
or o!r heal? c>e provid] :o is act+ )9 !
 scope ( practice ( t provid]'s lic5se  
or c]tification "u applicable ,/ate law 
& :o has a contractual relation%ip ) !  

plan1 respectively1 = furni%+ su* item  
or s]vice "u ! plan1 & includes         
facilities1 respectively4  7#b7 ,provid]
 ,! t]m provid] includes a heal? c>e    
facility4  7#c7 ,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]vice1       
reg>dless ( :e!r su* rate is calculat$  
bas$ on a set am\nt1 a fee s*$ule1 or an
 am\nt d]iv$ f ano!r am\nt1 or a =mula1 
or o!r me?od4  4  7,b7 ,cl]ical am5dm5t 
,! item relat+ to section #ihai ( !     
table ( sections = sub*apt] ,b ( *apt]  
#ajj ( ! ,int]nal ,rev5ue ,code ( #aihf 
is am5d$ to read z foll[s3  ,sec4 #ihai4
 ,transp>5cy 9 cov]age4  4  7#b7 ,,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 ,transp>5cy 9 cov]age    

7a7 ,co/-%>+ transp>5cy  7#a7 ,9 g5]al  
,= plan ye>s beg9n+ on or aft] ,janu>y  
#a1 #bjbf1 a gr\p heal? plan & a heal?  
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age %all p]mit an   
individual enroll$ "u su* plan or       
cov]age to le>n ! am\nt ( co/-%>+       
7includ+ d$uctibles1 copaym5ts1 &       
co9surance7 "u ! individual's plan or   
cov]age t ! individual w\ld be          
responsible = pay+ ) respect to !       
furni%+ ( a specific item or s]vice by a
 provid] 9 a timely mann] ^u ! reque/ ( 
! individual4 ,at a m9imum1 su*         
in=mation %all include ! in=mation      
specifi$ 9 p>agraph 7#b7 & %all be made 
available to su* individual ?r\gh a     
self-s]vice tool t meets ! requirem5ts (
 p>agraph 7#c7 or1 at ! option ( su*    
individual1 ?r\gh a pap] disclosure or  
phone or o!r electronic disclosure 7z   
select$ by su* individual & provid$ at  
no co/ to su* individual7 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 furni%$ by a    
heal? c>e provid] to an individual      
enroll$ "u 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 7c77 = su* item or s]vice4   
7,b7 ,if su* provid] is n a p>ticipat+  
provid] ) respect to su* item or s]vice1
 ! maximum all[$ am\nt or o!r doll>     
am\nt 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 *>ges4  7,c7 ,! e/imat$     
am\nt ( co/ %>+ 7includ+ d$uctibles1    
copaym5ts1 & co9surance7 t ! individual 
w incur = su* item or s]vice 7:i*1 9 !  
case su* item or s]vice is to be furni%$
 by a provid] describ$ 9 subp>agraph    
7,b71 %all be calculat$ us+ ! maximum   
all[$ am\nt or o!r doll> am\nt describ$ 

9 su* subp>agraph74  7,d7 ,! am\nt !    
individual 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 individuals   
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 ,9 ! case su* plan      
imposes any frequ5cy or volume          
limitations ) respect to su* item or    
s]vice 7exclud+ m$ical necessity        
det]m9ations71 ! am\nt t su* individual 
has accru$ t[>ds su* limitation )       
respect to su* item or s]vice4  7,f7    
,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 cov]age4  
7,g7 ,any %>$ sav+s 7su* z any cr$it1   
paym5t1 or o!r b5efit provid$ by su*    
plan or issu]7 available to ! individual
 ) respect to su* item or s]vice furni%$
 by su* provid] kn[n at ! "t su* reque/ 

is made4  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      
website 7or successor te*nology specifi$
 by ! ,secret>y72  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 timely & 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 or  7ii7 all provid]s t
 are p>ticipat+ provid]s ) respect to   
su* item or s]vice2  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]vice2 & 
7,f7 meets any o!r requirem5t det]m9$   

appropriate by ! ,secret>y to ensure !  
accessibility & usability ( in=mation   
provid$ ?r\gh su* tool4  ,! ,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 simil> items & s]vices4  7b7 ,rate & 
paym5t in=mation  7#a7 ,9 g5]al ,= plan 
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbf1 ea* gr\p heal? plan & heal?      
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age 7o!r ?an a      
gr&fa!r$ heal? plan 7z def9$ 9 section  
#abea7;e7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act77 %all1 = ea* mon?1 
n lat] ?an ! t5? day ( su* mon?1 make   
available to ! public ! rate & paym5t   
in=mation describ$ 9 p>agraph 7#b7 9    
accordance ) p>agraph 7#c74  7#b7 ,rate 
& paym5t in=mation describ$ ,= purposes 
( p>agraph 7#a71 ! rate & paym5t        
in=mation describ$ 9 ?is p>agraph is1 ) 
respect to a gr\p heal? plan or gr\p or 

individual heal? insurance cov]age1 !   
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 7express$ z a doll>      
am\nt7 9 effect z ( ! date on :i* su*   
in=mation is made public ) ea* provid] t
 is a p>ticipat+ provid] ) respect to   
su* item or s]vice4  7,b7 ,) respect to 
ea* drug 7id5tifi$ by national drug     
code7 = :i* b5efits are available "u su*
 plan or cov]age--  7i7 ! 9-network rate
 7express$ z a doll> am\nt7 9 effect z (
 ! fir/ day ( ! mon? 9 :i* su* in=mation
 is made public ) ea* provid] t is a    
p>ticipat+ provid] ) respect to su*     
drug2 &  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 ( publication to
 ea* provid] t 0 a p>ticipat+ provid] ) 
respect to su* drug1 brok5 d[n by ea*   
su* provid]1 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 ! 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]4  7#c7    
,mann] ( publication ,rate & paym5t     
in=mation requir$ to be made available  
"u ?is subsection %all be s made        
available 9 doll> am\nts ?r\gh sep>ate  
ma*9e-readable files 7& any successor   
te*nology1 su* z application program    
int]face te*nology1 det]m9$ appropriate 
by ! ,secret>y7 correspond+ to !        
in=mation describ$ 9 ea* ( subp>agraphs 
7,a7 ?r\gh 7,c7 ( p>agraph 7#b7 t meet  
su* requirem5ts z specifi$ by !         
,secret>y ?r\gh subregulatory guidance4 
,su* requirem5ts %all ensure t su* files
 are limit$ to an appropriate size1 d n 
include disclosure ( unnecess>y         

duplicative in=mation conta9$ 9 o!r     
files made available "u ?is subsection1 
are made available 9 a widely-available 
=mat ?r\gh a publicly-available website 
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$5tials4  7#d7  
,us] in/ructions ,ea* gr\p heal? plan & 
heal? insurance issu] (f]+ gr\p or      
individual heal? insurance cov]age %all 
make available to ! public in/ructions  
writt5 9 pla9 language expla9+ h[       
individuals may se>* = in=mation        
describ$ 9 p>agraph 7#b7 9 files        
submitt$ 9 accordance ) p>agraph 7#c74  
,! ,secret>y %all develop & publi% ?r\gh
 subregulatory guidance a template t su*
 a plan may use 9 develop+ in/ructions =
 purposes ( ! prec$+ s5t5ce4  7#e7      
,summ>y ,= ea* plan ye> beg9n+ on or    
aft] ,janu>y #a1 #bjbf1 ea* gr\p heal?  
plan & heal? insurance issu] (f]+ gr\p  

or individual heal? insurance cov]age   
%all make public a data file1 9 a mann] 
t ensures t su* file may be easily      
d[nload$ & read by /&>d spread%eet      
s(tw>e & t meets su* requirem5ts z      
e/abli%$ by ! ,secret>y1 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* 
plan ye>4 ,su* file %all include !      
foll[+3  7,a7 ,! mean1 m$ian1 &         
int]qu>tile range ( ! 9-network rate1 & 
! am\nt all[$ = an item or s]vice :5 n  
furni%$ by a p>ticipat+ provid]1 9      
effect z ( ! fir/ day ( su* plan ye> =  
ea* item or s]vice 7id5tifi$ by pay]    
id5tifi] approv$ or us$ by ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices7 = :i*       
b5efits are available "u ! plan or      
cov]age1 brok5 d[n by ! type ( provid]  
furni%+ ! item or s]vice & by !         
geographic area 9 :i* su* item or s]vice
 is furni%$4  7,b7 ,tr5ds 9 paym5t rates
 = su* items & s]vices ov] su* plan ye>1
 includ+ an id5tification ( in/ances 9  

:i* su* rates h increas$1 decreas$1 or  
rema9$ ! same4  7,c7 ,! "n ( su* plan1 a
 description ( ! type ( network (       
p>ticipat+ provid]s us$ by su* plan or  
cov]age1 &1 9 ! case ( a gr\p heal?     
plan1 a description ( :e!r su* plan is  
self-insur$ or fully-insur$4  7,d7 ,=   
ea* item or s]vice :i* is paid z "p ( a 
bundl$ rate--  7i7 a description ( !    
=mulae1 pric+ me?odologies1 or o!r      
in=mation us$ to calculate ! paym5t rate
 = su* bundle2 &  7ii7 a li/ ( ! items &
 s]vices includ$ 9 su* bundle4  7,e7 ,! 
p]c5tage ( items & s]vices t are paid = 
on a fee-=-s]vice basis & ! p]c5tage (  
items & s]vices t are paid = z "p ( a   
bundl$ rate1 capitat$ paym5t rate1 or   
o!r alt]native paym5t model4  7#f7      
,atte/ation ,ea* gr\p heal? plan & heal?
 insurance issu] (f]+ gr\p or individual
 heal? insurance cov]age %all po/1 along
 ) rate & paym5t in=mation made public  
by su* plan or issu]1 an atte/ation t   
su* in=mation is complete & accurate4   
7c7 ,accessibility ,a gr\p heal? plan & 

a heal? insurance issu] (f]+ gr\p or    
individual heal? insurance cov]age %all 
take reasonable /eps 7z specifi$ by !   
,secret>y7 to ensure t in=mation provid$
 9 response to a reque/ describ$ 9      
subsection 7a71 & rate & paym5t         
in=mation made public "u subsection 7b71
 is provid$ 9 pla91 easily und]/&able   
language & t int]pretation1             
translations1 & assi/ive s]vices are    
provid$ to ^? ) limit$ ,engli% pr(ici5cy
 & ^? ) disabilities4  7d7 ,def9itions  
,9 ?is section3  7#a7 ,p>ticipat+       
provid] ,! t]m p>ticipat+ provid] means1
 ) respect to an item or s]vice & a gr\p
 heal? plan or heal? insurance issu]    
(f]+ gr\p or individual heal? insurance 
cov]age1 a physician or o!r heal? c>e   
provid] :o is act+ )9 ! scope ( practice
 ( t provid]'s lic5se or c]tification "u
 applicable ,/ate law & :o has a        
contractual relation%ip ) ! plan or     
issu]1 respectively1 = furni%+ su* item 
or s]vice "u ! plan or cov]age1 &       
includes facilities1 respectively4  7#b7

 ,provid] ,! t]m provid] includes a     
heal? c>e facility4  7#c7 ,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]vice1 reg>dless ( :e!r su* rate is    
calculat$ bas$ on a set am\nt1 a fee    
s*$ule1 or an am\nt d]iv$ f ano!r am\nt1
 or a =mula1 or o!r me?od4  4  7#c7     
,,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          
,transp>5cy 9 cov]age  7a7 ,co/-,%>+    
transp>5cy  7#a7 ,9 g5]al ,= plan ye>s  
beg9n+ on or aft] ,janu>y #a1 #bjbf1 a  
gr\p heal? plan & a heal? insurance     
issu] (f]+ gr\p heal? insurance cov]age 
%all p]mit a p>ticipant or b5efici>y to 

le>n ! am\nt ( co/-%>+ 7includ+         
d$uctibles1 copaym5ts1 & co9surance7 "u 
! p>ticipant or b5efici>y's plan or     
cov]age t ! p>ticipant or b5efici>y w\ld
 be responsible = pay+ ) respect to !   
furni%+ ( a specific item or s]vice by a
 provid] 9 a timely mann] ^u ! reque/ ( 
! p>ticipant or b5efici>y4 ,at a m9imum1
 su* in=mation %all include ! in=mation 
specifi$ 9 p>agraph 7#b7 & %all be made 
available to su* p>ticipant or b5efici>y
 ?r\gh a self-s]vice tool t meets !     
requirem5ts ( p>agraph 7#c7 or1 at !    
option ( su* p>ticipant or b5efici>y1   
?r\gh a pap] disclosure or phone or o!r 
electronic disclosure 7z select$ by su* 
p>ticipant or b5efici>y & provid$ at no 
co/ to su* p>ticipant or b5efici>y7 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 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 7c77 = su* item or s]vice4   
7,b7 ,if su* provid] is n a p>ticipat+  
provid] ) respect to su* item or s]vice1
 ! maximum all[$ am\nt or o!r doll>     
am\nt t su* plan or cov]age w recognize 
z paym5t = su* item or s]vice1 along ) a
 notice t su* p>ticipant or b5efici>y   
may be liable = additional *>ges4  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+ ! maximum all[$ am\nt or  
o!r doll> am\nt describ$ 9 su*          
subp>agraph74  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 ,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,f7 ,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 cov]age4  7,g7 ,any %>$ sav+s 7su* z
 any cr$it1 paym5t1 or o!r b5efit       
provid$ by su* plan or issu]7 available 
to ! p>ticipant or b5efici>y ) respect  
to su* item or s]vice furni%$ by su*    
provid] kn[n at ! "t su* reque/ is made4
  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 website 7or successor    
te*nology specifi$ by ! ,secret>y72     
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 timely &      
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 or  7ii7 all provid]s t are 
p>ticipat+ provid]s ) respect to su*    
item or s]vice2  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]vice2 & 
7,f7 meets any o!r requirem5t det]m9$   
appropriate by ! ,secret>y to ensure !  
accessibility & usability ( in=mation   
provid$ ?r\gh su* tool4  ,! ,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 simil> items & s]vices4  7b7 ,rate & 
paym5t in=mation  7#a7 ,9 g5]al ,= plan 
ye>s beg9n+ on or aft] ,janu>y #a1      
#bjbf1 ea* gr\p heal? plan & heal?      
insurance issu] (f]+ gr\p heal?         
insurance cov]age 7o!r ?an a gr&fa!r$   
heal? plan 7z def9$ 9 section #abea7;e7 
( ! ,pati5t ,protection & ,af=dable ,c>e
 ,act77 %all1 = ea* mon?1 n lat] ?an !  
t5? day ( su* mon?1 make available to ! 
public ! rate & paym5t in=mation        
describ$ 9 p>agraph 7#b7 9 accordance ) 
p>agraph 7#c74  7#b7 ,rate & paym5t     
in=mation describ$ ,= purposes (        
p>agraph 7#a71 ! rate & paym5t in=mation
 describ$ 9 ?is p>agraph is1 ) respect  
to a gr\p heal? plan or gr\p heal?      
insurance cov]age1 ! 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   
7express$ z a doll> am\nt7 9 effect z ( 
! date on :i* su* in=mation is made     
public ) ea* provid] t is a p>ticipat+  
provid] ) respect to su* item or s]vice4
  7,b7 ,) respect to ea* drug 7id5tifi$ 
by national drug code7 = :i* b5efits are
 available "u su* plan or cov]age--  7i7
 ! 9-network rate 7express$ z a doll>   
am\nt7 9 effect z ( ! fir/ day ( ! mon? 
9 :i* su* in=mation is made public ) ea*
 provid] t is a p>ticipat+ provid] )    
respect to su* drug2 &  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 ( 
publication to ea* provid] t 0 a        
p>ticipat+ provid] ) respect to su*     
drug1 brok5 d[n by ea* su* provid]1 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 ! 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]4  7#c7 ,mann] ( publication 
,rate & paym5t in=mation requir$ to be  
made available "u ?is subsection %all be
 s made available 9 doll> am\nts ?r\gh  
sep>ate ma*9e-readable files 7& any     
successor te*nology1 su* z application  
program int]face te*nology1 det]m9$     
appropriate by ! ,secret>y7 correspond+ 
to ! in=mation describ$ 9 ea* (         
subp>agraphs 7,a7 ?r\gh 7,c7 ( p>agraph 
7#b7 t meet su* requirem5ts z specifi$  
by ! ,secret>y ?r\gh subregulatory      
guidance4 ,su* requirem5ts %all ensure t
 su* files are limit$ to an appropriate 
size1 d n include disclosure (          
unnecess>y duplicative in=mation conta9$
 9 o!r files made available "u ?is      
subsection1 are made available 9 a      
widely available =mat ?r\gh a publicly  

available website 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$5tials4  7#d7 ,us]       
in/ructions ,ea* gr\p heal? plan & heal?
 insurance issu] (f]+ gr\p heal?        
insurance cov]age %all make available to
 ! public in/ructions writt5 9 pla9     
language expla9+ h[ individuals may se>*
 = in=mation describ$ 9 p>agraph 7#b7 9 
files submitt$ 9 accordance ) p>agraph  
7#c74 ,! ,secret>y %all develop & publi%
 ?r\gh subregulatory guidance a template
 t su* a plan may use 9 develop+        
in/ructions = purposes ( ! prec$+       
s5t5ce4  7#e7 ,summ>y ,= ea* plan ye>   
beg9n+ on or aft] ,janu>y #a1 #bjbf1 ea*
 gr\p heal? plan & heal? insurance issu]
 (f]+ gr\p heal? insurance cov]age %all 
make public a data file1 9 a mann] t    
ensures t su* file may be easily        
d[nload$ & read by /&>d spread%eet      

s(tw>e & t meets su* requirem5ts z      
e/abli%$ by ! ,secret>y1 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* 
plan ye>4 ,su* file %all include !      
foll[+3  7,a7 ,! mean1 m$ian1 &         
int]qu>tile range ( ! 9-network rate1 & 
! am\nt all[$ = an item or s]vice :5 n  
furni%$ by a p>ticipat+ provid]1 9      
effect z ( ! fir/ day ( su* plan ye> =  
ea* item or s]vice 7id5tifi$ by pay]    
id5tifi] approv$ or us$ by ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices7 = :i*       
b5efits are available "u ! plan or      
cov]age1 brok5 d[n by ! type ( provid]  
furni%+ ! item or s]vice & by !         
geographic area 9 :i* su* item or s]vice
 is furni%$4  7,b7 ,tr5ds 9 paym5t rates
 = su* items & s]vices ov] su* plan ye>1
 includ+ an id5tification ( in/ances 9  
:i* su* rates h increas$1 decreas$1 or  
rema9$ ! same4  7,c7 ,! "n ( su* plan1 a
 description ( ! type ( network (       
p>ticipat+ provid]s us$ by su* plan or  

cov]age1 &1 9 ! case ( a gr\p heal?     
plan1 a description ( :e!r su* plan is  
self-insur$ or fully-insur$4  7,d7 ,=   
ea* item or s]vice :i* is paid z "p ( a 
bundl$ rate--  7i7 a description ( !    
=mulae1 pric+ me?odologies1 or o!r      
in=mation us$ to calculate ! paym5t rate
 = su* bundle2 &  7ii7 a li/ ( ! items &
 s]vices includ$ 9 su* bundle4  7,e7 ,! 
p]c5tage ( items & s]vices t are paid = 
on a fee-=-s]vice basis & ! p]c5tage (  
items & s]vices t are paid = z "p ( a   
bundl$ rate1 capitat$ paym5t rate1 or   
o!r alt]native paym5t model4  7#f7      
,atte/ation ,ea* gr\p heal? plan & heal?
 insurance issu] (f]+ gr\p heal?        
insurance cov]age %all po/1 along ) rate
 & paym5t in=mation made public by su*  
plan or issu]1 an atte/ation t su*      
in=mation is complete & accurate4  7c7  
,accessibility ,a gr\p heal? plan & a   
heal? insurance issu] (f]+ gr\p heal?   
insurance cov]age %all take reasonable  
/eps 7z specifi$ by ! ,secret>y7 to     
ensure t in=mation provid$ 9 response to

 a reque/ describ$ 9 subsection 7a71 &  
rate & paym5t in=mation made public "u  
subsection 7b71 is provid$ 9 pla91      
easily und]/&able language & t          
int]pretation1 translations1 & assi/ive 
s]vices are provid$ to ^? ) limit$      
,engli% pr(ici5cy & ^? ) disabilities4  
7d7 ,def9itions ,9 ?is section3  7#a7   
,p>ticipat+ provid] ,! t]m p>ticipat+   
provid] means1 ) respect to an item or  
s]vice & a gr\p heal? plan or heal?     
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age1 a physician or 
o!r heal? c>e provid] :o is act+ )9 !   
scope ( practice ( t provid]'s lic5se or
 c]tification "u applicable ,/ate law & 
:o has a contractual relation%ip ) !    
plan or issu]1 respectively1 = furni%+  
su* item or s]vice "u ! plan or cov]age1
 & includes facilities1 respectively4   
7#b7 ,provid] ,! t]m provid] includes a 
heal? c>e facility4  7#c7 ,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]vice1 reg>dless ( :e!r su* rate is    
calculat$ bas$ on a set am\nt1 a fee    
s*$ule1 or an am\nt d]iv$ f ano!r am\nt1
 or a =mula1 or o!r me?od4  4  7,b7     
,cl]ical am5dm5t ,! table ( cont5ts 9   
section #a ( ! ,employee ,retirem5t     
,income ,security ,act ( #aigd is am5d$ 
by /rik+ ! item relat+ to section #gai &
 ins]t+ ! foll[+ new item3  ,sec4 #gai4 
,transp>5cy 9 cov]age4  4  7b7          
,application programm+ int]face report  
,n lat] ?an ,janu>y #a1 #bjbe1 &        
annually !reaft]1 ! ,secret>y ( ,heal? &
 ,human ,s]vices %all1 9 consultation ) 
! ,(fice ( ! ,national ,coord9ator =    
,heal? ,in=mation ,te*nology1 ,dep>tm5t 
( ,labor1 ! ,dep>tm5t ( ! ,treasury1 &  
/akehold]s1 submit to ! ,h\se           
,committees on ,education & ! ,work=ce1 

,en]gy & ,comm]ce1 & ,ways & ,means1 & !
 ,s5ate ,committees on ,f9ance & ,heal?1
 ,education1 ,labor1 & ,p5sions a report
 on ! use ( /&>ds-bas$ application      
programm+ int]faces 79 ?is subsection   
ref]r$ to z ,a,p,is7 to facilitate      
access to heal? c>e price transp>5cy    
in=mation & ! int]op]ability ( o!r      
m$ical in=mation4 ,su* report %all      
include an evaluation ( ! capacity ( !  
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,dep>tm5t ( ,labor1 & ! ,dep>tm5t ( !   
,treasury to regulate & implem5t /&>ds  
relat$ to ,a,p,is & recomm5dations =    
improv+ su* capacity4 ,su* report %all  
include ! foll[+3 7#a7 ,a description ( 
curr5t use1 & propos$ use1 ( ,a,p,is "u 
,f$]al rules to facilitate              
int]op]ability1 includ+ in=mation relat$
 to capacity con/ra9ts )9 ! ag5cies1    
b>ri]s to adoption1 privacy & security1 
adm9i/rative burd5s & effici5cies1 c>e  
coord9ation1 & levels ( compliance4     
7#b7 ,a description ( ! feasibility (   
ag5cy p>ticipation 9 ! developm5t (     

,a,p,is to enable application access to 
price transp>5cy data "u ! am5dm5ts made
 by subsection 7a74  7#c7 ,a            
specification ( ! timel9e = :i* su* data
 /&>ds c be requir$ to make su* data    
accessible via an ,,api4  7#d7 ,an      
analysis ( ! b5efits & *all5ges (       
implem5t+ /&>ds-bas$ ,a,p,is = price    
transp>5cy data1 includ+ ! ability =    
consum]s to access rate & paym5t        
in=mation & ! am\nt ( co/-%>+ 7includ+  
d$uctibles1 copaym5ts1 & co9surance7 "u 
! consum]'s plan ?r\gh ?ird-p>ty        
int]net-bas$ tools & applications4  7#e7
 ,an analysis ( ! impact t ,a,p,is :i*  
provide real-"t access to pric+ &       
co/-%>+ in=mation may h 9 increas+ !    
am\nt ( s]vices %oppable = individuals1 
su* z by /&>diz+ m heal? c>e sp5d via   
episode bundles4  7#f7 ,an analysis (   
:i* heal? c>e items & s]vices may be    
useful "u ,,api1 su* z ^? = :i* prices  
*ange ) ! greate/ frequ5cy4  7#g7 ,an   
analysis ( ! co/ ( ,,api /&>ds          
implem5tation on issu]s1 employ]s1 & o!r

 private-sector entities4  7#h7 ,an     
analysis ( ! ability ( ,/ate regulators 
to en=ce ,,api /&>ds & ! co/s to !      
,f$]al ,gov]nm5t & ,/ates to regulate & 
en=ce ,,api /&>ds4  7#i7 ,an analysis ( 
! int]action ) ,,api /&>ds & ,f$]al     
heal? in=mation privacy /&>ds4  7c7     
,provid] tool report  7#a7 ,9 g5]al ,n  
lat] ?an #a ye> aft] ! date ( ! enactm5t
 ( ?is ,act1 ,! ,secret>y ( ,heal? &    
,human ,s]vices1 act+ ?r\gh !           
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices1 %all1 9 consultation 
) /akehold]s1 conduct a /udy & submit to
 ! ,h\se ,committees on ,education & !  
,work=ce1 ,en]gy & ,comm]ce1 & ,ways &  
,means1 & ! ,s5ate ,committees on       
,f9ance & ,heal?1 ,education1 ,labor1 & 
,p5sions a report on ! usefulness &     
feasibility ( ! e/abli%m5t ( a provid]  
tool by a gr\p heal? plan1 or a heal?   
insurance issu] (f]+ gr\p & individual  
heal? insurance cov]age1 9 facilitat+ ! 
provision ( in=mation made available    
pursuant to ! am5dm5ts made by          

subsection 7a74 ,su* report %all include
 ! foll[+3 7,a7 ,a description ( !      
feasibility ( e/abli%+ a requirem5t = ! 
v>i\s types ( plans & cov]age to (f] su*
 a provid] tool1 includ+ any *all5ges to
 e/abli%+ a provid] tool us+ ! same     
te*nology plat=m z ! self-s]vice tool   
describ$ 9 su* am5dm5ts4  7,b7 ,an      
evaluation on ! usefulness ( a provid]  
tool to aid pati5t-decision mak+ & h[   
su* tool w\ld coord9ate ) o!r in=mation 
available to a pati5t & _! provid] "u   
o!r ,f$]al requirem5ts 9 place or "u    
consid]ation4  7,c7 ,an evaluation (    
:e!r ! in=mation provid$ by su* tool    
w\ld be duplicative ( ! advanc$         
explanation ( b5efits requir$ "u ,f$]al 
law or any o!r exi/+ requirem5t4  7,d7  
,a description ( ! usability & expect$  
utilization ( su* tool among provid]s1  
includ+ among diff]5t provid] types4    
7,e7 ,an analysis ( ! impact ( a provid]
 tool 9 value-bas$ c>e arrangem5ts4     
7,f7 ,an analysis on ! pot5tial impact (
 ! provid] tool on-- 7i7 pati5ts'       

out-(-pocket sp5d+2  7ii7 plan design1  
includ+ impacts on co/-%>+ requirem5ts2 
7iii7 c>e coord9ation & quality2  7iv7  
plan premiums2  7v7 ov]all heal? c>e    
sp5d+ & utilization2 &  7vi7 heal? c>e  
access 9 rural areas4  7,g7 ,an analysis
 ( ! feasibility ( a provid] tool to    
include additional functionality to     
facilitate & improve ! adm9i/ration ( ! 
requirem5ts on provid]s to submit       
notifications to su* plan or cov]age "u 
section #bgii;,b-#f ( ! ,public ,heal?  
,s]vice ,act & ! requirem5ts on su* plan
 or cov]age to provide an advanc$       
explanation ( b5efits to individuals "u 
section #bgii;,a-#a7;f7 ( su* ,act4     
7,h7 ,an analysis ( :i* heal? c>e items 
& s]vices1 w\ld be mo/ useful = pati5ts 
utiliz+ a provid] tool4  7,i7 ,an       
analysis ( rulemak+ requir$ to ensure   
su* a tool complies ) f$]al heal?       
in=mation privacy /&>ds4  7,j7 ,an      
analysis ( ! burd5 & co/ ( ! creation ( 
a provid] tool by plans & cov]age on    
provid]s1 issu]s1 employ]s1 & o!r       

private-sector entities4  7,k7 ,an      
analysis ( ! ability ( /ate regulators  
to en=ce provid] tool /&>ds & ! co/s to 
! ,dep>tm5t & /ates to regulate & en=ce 
provid] tool /&>ds4  7#b7 ,def9ition ,! 
t]m provid] tool means a tool design$ to
 facilitate ! provision ( in=mation made
 available pursuant to ! am5dm5ts made  
by subsection 7a7 & e/abli%$ by a gr\p  
heal? plan or a heal? insurance issu]   
(f]+ gr\p & individual heal? insurance  
cov]age t all[s provid]s to access !    
in=mation su* plan or cov]age mu/       
provide ?r\gh ! self-s]vice tool        
describ$ 9 su* am5dm5ts to an individual
 ) :om ! provid] is actively treat+ at !
 "t ( su* reque/1 ^u ! reque/ ( !       
provid]1 & ) ! cons5t ( su* individual4 
7d7 ,reports  7#a7 ,compliance ,n lat]  
?an ,janu>y #a1 #bjbg1 ! ,comptroll]    
,g5]al ( ! ,unit$ ,/ates %all submit to 
,congress a report conta9+--  7,a7 an   
analysis ( compliance ) ! am5dm5ts made 
by ?is section2  7,b7 an analysis (     
en=cem5t ( su* am5dm5ts by ! ,secret>ies

 ( ,heal? & ,human ,s]vices1 ,labor1 & !
 ,treasury2  7,c7 recomm5dations relat+ 
to improv+ su* en=cem5t2 &  7,d7        
recomm5dations relat+ to improv+ public 
disclosure1 & public aw>5ess1 (         
in=mation requir$ to be made available  
by gr\p heal? plans & heal? insurance   
issu]s pursuant to su* am5dm5ts4  7#b7  
,prices ,n lat] ?an ,janu>y #a1 #bjbh1 &
 bi5nially !reaft]1 ! ,secret>ies (     
,heal? & ,human ,s]vices1 ,labor1 & !   
,treasury %all jo9tly submit to         
,congress a report conta9+ an assessm5t 
( diff]5ces 9 negotiat$ prices 7& any   
tr5ds 9 su* prices7 9 ! private m>ket   
betwe5-- 7,a7 rural & urban areas2  7,b7
 ! individual1 small gr\p1 & l>ge gr\p  
m>kets2  7,c7 consolidat$ &             
nonconsolidat$ heal? c>e provid] areas  
7z specifi$ by ! ,secret>y ( ,heal? &   
,human ,s]vices72  7,d7 nonpr(it &      
=-pr(it hospitals2  7,e7 nonpr(it &     
=-pr(it insur]s2 &  7,f7 insur]s s]v+   
local or regional areas & insur]s s]v+  
multi/ate or national areas4  7e7       

,quality report ,n lat] ?an #a ye> aft] 
! date ( enactm5t ( ?is subsection1 !   
,secret>ies ( ,heal? & ,human ,s]vices1 
,labor1 & ! ,treasury %all jo9tly 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  7f7 ,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 #gbaeh71 = any plan ye>      
beg9n+ be=e ,janu>y #a1 #bjbf4  #ajf4   
,ph>macy b5efits price transp>5cy  7a7  

,,phsa ,title ,,xxvii ( ! ,public ,heal?
 ,s]vice ,act 7#db ,u4,s4,c4 #cjj;gg et 
seq47 is am5d$--  7#a7 9 "p ,d 7#db     
,u4,s4,c4 #cjj;gg-#aaa et seq471 by add+
 at ! end ! foll[+ new section3         
#bgii;,a-#aa4 ,ov]sight ( ph>macy       
b5efits manag] s]vices  7a7 ,9 g5]al ,= 
plan ye>s beg9n+ on or aft] ! date t is 
#b ye>s aft] ! date ( enactm5t ( ?is    
section1 a gr\p heal? plan or a heal?   
insurance issu] (f]+ gr\p heal?         
insurance cov]age1 or an entity or      
subsidi>y provid+ ph>macy b5efits       
managem5t s]vices on behalf ( su* a plan
 or issu]1 %all n ent] into a contract )
 a drug manufactur]1 di/ributor1        
:olesal]1 subcontractor1 rebate         
aggregator1 or any o!r ?ird p>ty t      
limits 7or delays beyond ! applicable   
report+ p]iod describ$ 9 subsection     
7b77#a77 ! disclosure ( in=mation to    
gr\p heal? plans 9 su* a mann] t prev5ts
 su* plan1 issu]1 or entity f mak+ !    
reports describ$ 9 subsection 7b74  7b7 
,reports  7#a7 ,9 g5]al ,) respect to   

plan ye>s beg9n+ on or aft] ! date t is 
#b ye>s aft] ! date ( enactm5t ( ?is    
section1 n less frequ5tly ?an e #f mon?s
 7or at ! reque/ ( a gr\p heal? plan1 n 
less frequ5tly ?an qu>t]ly1 b "u ! same 
conditions1 t]ms1 & co/ ( ! semiannual  
report "u ?is subsection71 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 ( su* a plan or issu]1
 %all submit to ! gr\p heal? plan a     
report 9 accordance ) ?is section4 ,ea* 
su* report %all be made available to su*
 gr\p heal? plan 9 a ma*9e-readable =mat
 & %all include ! in=mation describ$ 9  
p>agraph 7#b74  7#b7 ,in=mation describ$
 ,= purposes ( p>agraph 7#a71 !         
in=mation describ$ 9 ?is p>agraph is1 ) 
respect to drugs cov]$ by a gr\p heal?  
plan or heal? insurance issu] (f]+ gr\p 
heal? insurance cov]age dur+ ea* report+
 p]iod--  7,a7 9 ! case ( su* a plan    
(f]$ by a specifi$ l>ge employ] 7or su* 
cov]age (f]$ 9 connection ) su* a plan  

(f]$ by a specifi$ l>ge employ]7-- 7i7 a
 li/ ( drugs = :i* a claim 0 fil$ &1 )  
respect to ea* su* drug on su* li/--    
7,i7 ! br& "n1 *emical entity1 &        
,national ,drug ,code2  7,,ii7 ! type ( 
disp5s+ *annel us$ to furni% su* drug1  
includ+ retail1 mail ord]1 or specialty 
ph>macy2  7,,iii7 ) respect to ea* drug 
disp5s$ "u ea* type ( disp5s+ *annel    
7includ+ retail1 mail ord]1 or specialty
 ph>macy7-- 7aa7 :e!r su* drug is a br& 
"n drug or a g5]ic drug1 &-- 7,,aa7 9 ! 
case ( a br& "n drug1 ! :olesale        
acquisition co/1 li/$ z co/ p] days     
supply & co/ p] dosage unit1 on ! date  
su* drug 0 disp5s$2 & 7,,bb7 9 ! case ( 
a g5]ic drug1 ! av]age :olesale price1  
li/$ z co/ p] days supply & co/ p]      
dosage unit1 on ! date su* drug 0       
disp5s$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7
 p>ticipants1 b5efici>ies1 & enrollees =
 :om a claim = su* drug 0 fil$2 7,,cc7  
dosage units p] fill ( su* drug2 &      

7,,dd7 days supply ( su* drug p] fill2  
7,,iv7 ! net price p] c\rse ( treatm5t  
or s+le fill1 su* z a #cj-;day supply or
 #ij-;day supply to ! plan or cov]age   
aft] manufactur] rebates1 fees1 & o!r   
remun]ation or adju/m5ts2  7,v7 ! total 
am\nt ( out-(-pocket sp5d+ by           
p>ticipants1 b5efici>ies1 & enrollees on
 su* drug1 includ+ sp5d+ ?r\gh          
copaym5ts1 co9surance1 & d$uctibles2    
7,,vi7 ! total net sp5d+ by ! plan or   
cov]age dur+ ! report+ p]iod2  7,,vii7 !
 total am\nt receiv$1 or expect$ to be  
receiv$1 by ! plan or cov]age f any     
entity 9 drug manufactur] rebates1 fees1
 alt]native disc\nts1 & all o!r         
remun]ation receiv$ f an entity or any  
?ird p>ty 7includ+ gr\p pur*as+         
organizations7 o!r ?an ! plan sponsor2  
7,,viii7 ! total am\nt receiv$1 or      
expect$ to be receiv$ by ! plan or      
issu]1 f drug manufactur]s 9 rebates1   
fees1 alt]native disc\nts1 or o!r       
remun]ation--  7aa7 t has be5 paid1 or  
is to be paid1 by drug manufactur]s =   

claims incurr$ dur+ ! report+ p]iod2 &  
7bb7 t is relat$ to utilization rebates 
= su* drug2 &  7,,ix7 to ! ext5t        
feasible1 in=mation on ! total am\nt (  
remun]ation1 includ+ copaym5t assi/ance 
doll>s paid1 copaym5t c>ds appli$1 or   
o!r disc\nts provid$ by ea* drug        
manufactur] 7or entity adm9i/]+ copay   
assi/ance on behalf ( su* drug          
manufactur]7 to ! p>ticipants1          
b5efici>ies1 & enrollees enroll$ 9 su*  
plan or cov]age = su* drug2  7ii7 = ea* 
category or class ( drugs = :i* a claim 
0 fil$1 a breakd[n ( ! total gross sp5d+
 on drugs 9 su* category or class be=e  
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f drug     
manufactur]s1 & ! net sp5d+ aft] su*    
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f drug     
manufactur]s1 includ+--  7,i7 ! numb] ( 
p>ticipants1 b5efici>ies1 & enrollees :o
 fill$ a prescription = a drug 9 su*    
category or class1 includ+ ! ,national  
,drug ,code = ea* su* drug2  7,,ii7 if  

applicable1 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,,iii7 ! total out-(-pocket sp5d+ "u ! 
plan or cov]age by p>ticipants1         
b5efici>ies1 & enrollees1 includ+ sp5d+ 
?r\gh copaym5ts1 co9surance1 &          
d$uctibles2  7iii7 9 ! case ( a drug =  
:i* gross sp5d+ by su* plan1 cov]age1 or
 entity exce$$ #aj1jjj dur+ ! report+   
p]iod--  7,i7 a li/ ( all o!r drugs 9 ! 
same !rapeutic category or class2 &     
7,,ii7 ! rationale = ! =mul>y placem5t (
 su* drug 9 t !rapeutic category or     
class1 if applicable2 &  7iv7 9 ! case  
su* plan or cov]age 7or an entity       
provid+ ph>macy b5efits managem5t       
s]vices on behalf ( su* plan or cov]age7
 has an affiliat$ ph>macy or ph>macy "u 
common own]%ip-- 7,i7 ! p]c5tage ( total
 prescriptions disp5s$ by su* ph>macies 
to individuals enroll$ 9 su* plan or    
cov]age2  7,,ii7 a li/ ( all drugs      
disp5s$ by su* ph>macies to individuals 

enroll$ 9 su* plan or cov]age1 &1 )     
respect to ea* drug disp5s$-- 7aa7 !    
am\nt *>g$1 p] dosage unit1 p] #cj-;day 
supply1 or p] #ij-;day supply 7z        
applicable7 to ! plan or issu]1 & to    
p>ticipants1 b5efici>ies1 & enrollees   
enroll$ 9 su* plan or cov]age2  7bb7 !  
m$ian am\nt *>g$ to su* plan or issu]1 &
 ! int]qu>tile range ( ! co/s1 p] dosage
 unit1 p] #cj-;day supply1 & p] #ij-;day
 supply1 includ+ am\nts paid by !       
p>ticipants1 b5efici>ies1 & enrollees1  
: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  7cc7 ! l[e/ co/ p] dosage  
unit1 p] #cj-;day supply & p] #ij-;day  
supply1 = ea* su* drug1 includ+ am\nts  
*>g$ to ! plan & p>ticipants1           
b5efici>ies1 & enrollees1 t is available
 f any ph>macy includ$ 9 ! network ( su*
 plan or cov]age2 &  7dd7 ! net         
acquisition co/ p] dosage unit1 p]      
#cj-;day supply1 & p] #ij-;day supply1  

if su* drug is subject to a maximum     
price disc\nt2  7,b7 9 ! case ( a plan  
or cov]age n describ$ 9 subp>agraph     
7,a7--  7i7 ! total net sp5d+ by ! plan 
or cov]age = all drugs cov]$ by su* plan
 or cov]age dur+ su* report+ p]iod2     
7ii7 ! total am\nt receiv$1 or expect$  
to be receiv$1 by ! plan or cov]age f   
any entity 9 drug manufactur] rebates1  
fees1 alt]native disc\nts1 & all o!r    
remun]ation receiv$ f an entity or any  
?ird p>ty 7includ+ gr\p pur*as+         
organizations7 o!r ?an ! plan sponsor = 
all su* drugs2 &  7iii7 to ! ext5t      
feasible1 in=mation on ! total am\nt (  
remun]ation1 includ+ copaym5t assi/ance 
doll>s paid1 copaym5t c>ds appli$1 or   
o!r disc\nts provid$ by ea* drug        
manufactur] 7or entity adm9i/]+ copay   
assi/ance on behalf ( su* drug          
manufactur]7 to ! p>ticipants1          
b5efici>ies1 & enrollees enroll$ 9 su*  
plan or cov]age = su* drugs2  7,c7      
am\nts paid directly or indirectly 9    
rebates1 fees1 or any o!r type (        

comp5sation 7z def9$ 9 section          
#djh7;b77#b77;,b77ii77dd77,,aa7 ( !     
,employee ,retirem5t ,income ,security  
,act7 to brok]s1 consultants1 advisors1 
or any o!r individual or firm1 = !      
ref]ral ( ! gr\p heal? plan's or heal?  
insurance issu]'s bus9ess to an entity  
provid+ ph>macy b5efits managem5t       
s]vices1 includ+ ! id5tity ( ! recipi5t 
( su* am\nts2  7,d7 an explanation ( any
 b5efit design p>amet]s t enc\rage or   
require p>ticipants1 b5efici>ies1 &     
enrollees 9 su* 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 directly or         
indirectly fund$ by su* entity2 &  7,e7 
total gross sp5d+ on all drugs dur+ !   
report+ p]iod4  7#c7 ,privacy           
requirem5ts  7,a7 ,9 g5]al ,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 #acdjb7;a7 ( ! ,heal? ,in=mation
 ,te*nology = ,cl9ical ,heal? ,act &    
consi/5t ) ! ,,hipaa privacy regulations
 7z def9$ 9 section #aahj7;b77#c7 ( !   
,social ,security ,act7 & %all re/rict !
 use & disclosure ( su* in=mation       
accord+ to su* privacy1 security1 &     
brea* notification regulations & su*    
,,hipaa privacy regulations4  7,b7      
,additional requirem5ts  7i7 ,9 g5]al   
,an entity provid+ ph>macy b5efits      
managem5t s]vices on behalf ( a gr\p    
heal? plan or heal? insurance issu] (f]+
 gr\p heal? insurance cov]age t submits 
a report "u p>agraph 7#a7 %all ensure t 
su* report conta9s only summ>y heal?    
in=mation1 z def9$ 9 section            
#afd4ejd7;a7 ( title #de1 ,code ( ,f$]al

 ,regulations 7or successor             
regulations74  7ii7 ,re/rictions ,a gr\p
 heal? plan %all comply ) section       
#afd4ejd7;f7 ( title #de1 ,code ( ,f$]al
 ,regulations 7or a successor           
regulation7 & a plan sponsor %all act 9 
accordance ) ! t]ms ( ! agreem5t        
describ$ 9 su* section4  7,c7 ,rule (   
con/ruction ,no?+ 9 ?is section %all be 
con/ru$ to modify ! requirem5ts = !     
creation1 receipt1 ma9t5ance1 or        
transmission ( protect$ heal? in=mation 
"u ! ,,hipaa privacy regulations 7z     
def9$ 9 section #aahj7;b77#c7 ( !       
,social ,security ,act74  7#d7          
,disclosure & r$isclosure  7,a7         
,limitation to bus9ess associates ,a    
gr\p heal? plan receiv+ a report "u     
p>agraph 7#a7 may disclose su* in=mation
 only to ! entity f :i* ! report 0      
receiv$ or to t entity's bus9ess        
associates z def9$ 9 section #afj4ajc ( 
title #de1 ,code ( ,f$]al ,regulations  
7or successor regulations7 or z p]mitt$ 
by ! ,,hipaa ,privacy ,rule 7#de ,,cfr  

p>ts #afj & #afd1 subp>ts ,a & ,e74     
7,b7 ,cl>ification reg>d+ public        
disclosure ( in=mation ,no?+ 9 ?is      
section %all prev5t 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 ( su* a plan or cov]age1 f plac+ 
reasonable re/rictions on ! public      
disclosure ( ! in=mation conta9$ 9 a    
report describ$ 9 p>agraph 7#a71 except 
t su* plan1 issu]1 or entity may n      
re/rict disclosure ( su* report to !    
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,dep>tm5t ( ,labor1 ! ,dep>tm5t ( !     
,treasury1 or ! ,comptroll] ,g5]al ( !  
,unit$ ,/ates4  7,c7 ,limit$ =m ( report
 ,! ,secret>y %all def9e ?r\gh rulemak+ 
a limit$ =m ( ! report "u p>agraph 7#a7 
requir$ ) respect to gr\p heal? plans   
:]e ! plan sponsors ( su* plans 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#e7 ,report to ,,gao ,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 ( su* plan  
or cov]age1 %all submit to ! ,comptroll]
 ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/  
#d reports submitt$ to a gr\p heal? plan
 "u p>agraph 7#a7 & o!r su* reports z   
reque/$1 9 accordance ) ! privacy       
requirem5ts "u p>agraph 7#c71 !         
disclosure & r$isclosure /&>ds "u       
p>agraph 7#d71 ! /&>ds specifi$ pursuant
 to p>agraph 7#f71 & su* o!r in=mation t
 ! ,comptroll] ,g5]al det]m9es necess>y 
to c>ry out ! /udy "u section #ajf7;d7 (
 ! ,l[] ,co/s1 ,m ,transp>5cy ,act4     
7#f7 ,/&>d =mat ,n lat] ?an #a ye> aft] 
! date ( enactm5t ( ?is section1 !      
,secret>y %all specify ?r\gh rulemak+   
/&>ds = gr\p heal? plans1 heal?         
insurance issu]s (f]+ gr\p heal?        
insurance cov]age1 & entities provid+   
ph>macy b5efits managem5t s]vices on    
behalf ( su* plans or cov]age1 requir$  
to submit reports "u p>agraph 7#a7 to   

submit su* reports 9 a /&>d =mat4  7c7  
,en=cem5t  7#a7 ,9 g5]al ,! ,secret>y   
%all en=ce ?is section4  7#b7 ,failure  
to provide in=mation ,a heal? insurance 
issu] or an entity provid+ ph>macy      
b5efits managem5t s]vices on behalf (   
su* plan or cov]age t violates          
sub-section 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$4  7#c7 ,false     
in=mation ,a heal? insurance issu] or an
 entity provid+ ph>macy b5efits         
managem5t s]vices on behalf ( su* a plan
 or cov]age t kn[+ly provides false     
in=mation "u ?is section %all be subject
 to a civil money p5alty 9 an am\nt n to
 exce$ #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#d7 ,proc$ure ,!    
provisions ( section #aabh;,a ( !       
,social ,security ,act1 o!r ?an         

subsections 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$+ 
"u su* section4  7#e7 ,waiv]s ,!        
,secret>y may waive p5alties "u p>agraph
 7#b71 or ext5d ! p]iod ( "t =          
compliance ) a requirem5t ( ?is section1
 = an entity 9 violation ( ?is section t
 has made a good-fai? ef=t to comply ) !
 requirem5ts 9 ?is section4  7d7 ,rule (
 con/ruction ,no?+ 9 ?is section %all be
 con/ru$ to p]mit a gr\p heal? plan1    
heal? insurance issu]1 or entity provid+
 ph>macy b5efits managem5t s]vices on   
behalf ( su* plan or cov]age1 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 or 7b7 by
 entities subject to su* subsection4    
7e7 ,def9itions ,9 ?is section3  7#a7   
,specifi$ l>ge employ] ,! t]m specifi$  

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 #bgbc 7#db ,u4,s4,c4            
#cjj;gg-#bb7-- 7,a7 9 subsection 7a7--  
7i7 9 p>agraph 7#a71 by ins]t+ 7o!r ?an 
subsections 7a7 & 7b7 ( section         
#bgii;,a-#aa7 aft] "p ,d2 &  7ii7 9     
p>agraph 7#b71 by ins]t+ 7o!r ?an       
subsections 7a7 & 7b7 ( section         
#bgii;,a-#aa7 aft] "p ,d2 &  7,b7 9     
subsection 7b7-- 7i7 9 p>agraph 7#a71 by
 ins]t+ 7o!r ?an subsections 7a7 & 7b7 (
 section #bgii;,a-#aa7 aft] "p ,d2  7ii7
 9 p>agraph 7#b77;,a71 by ins]t+ 7o!r   
?an subsections 7a7 & 7b7 ( section     
#bgii;,a-#aa7 aft] "p ,d2 &  7iii7 9    

p>agraph 7#b77;,c77ii71 by ins]t+ 7o!r  
?an subsections 7a7 & 7b7 ( section     
#bgii;,a-#aa7 aft] "p ,d4  7b7 ,,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$-- 7,a7 9 subp>t ,b ( "p  
#g 7#bi ,u4,s4,c4 #aahe et seq471 by    
add+ at ! end ! foll[+3  #gbf4 ,ov]sight
 ( ph>macy b5efit manag] s]vices  7a7 ,9
 g5]al ,= plan ye>s beg9n+ on or aft] ! 
date t is #b ye>s aft] ! date ( enactm5t
 ( ?is section1 a gr\p heal? plan or a  
heal? insurance issu] (f]+ gr\p heal?   
insurance cov]age1 or an entity or      
subsidi>y provid+ ph>macy b5efits       
managem5t s]vices on behalf ( su* a plan
 or issu]1 %all n ent] into a contract )
 a drug manufactur]1 di/ributor1        
:olesal]1 subcontractor1 rebate         
aggregator1 or any o!r ?ird p>ty t      
limits 7or delays beyond ! applicable   
report+ p]iod describ$ 9 subsection     
7b77#a77 ! disclosure ( in=mation to    
gr\p heal? plans 9 su* a mann] t prev5ts

 su* plan1 issu]1 or entity f mak+ !    
reports describ$ 9 subsection 7b74  7b7 
,reports  7#a7 ,9 g5]al ,) respect to   
plan ye>s beg9n+ on or aft] ! date t is 
#b ye>s aft] ! date ( enactm5t ( ?is    
section1 n less frequ5tly ?an e #f mon?s
 7or at ! reque/ ( a gr\p heal? plan1 n 
less frequ5tly ?an qu>t]ly1 b "u ! same 
conditions1 t]ms1 & co/ ( ! semiannual  
report "u ?is subsection71 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 ( su* a plan or issu]1
 %all submit to ! gr\p heal? plan a     
report 9 accordance ) ?is section4 ,ea* 
su* report %all be made available to su*
 gr\p heal? plan 9 a ma*9e-readable =mat
 & %all include ! in=mation describ$ 9  
p>agraph 7#b74  7#b7 ,in=mation describ$
 ,= purposes ( p>agraph 7#a71 !         
in=mation describ$ 9 ?is p>agraph is1 ) 
respect to drugs cov]$ by a gr\p heal?  
plan or heal? insurance issu] (f]+ gr\p 
heal? insurance cov]age dur+ ea* report+

 p]iod-- 7,a7 9 ! case ( su* a plan (f]$
 by a specifi$ l>ge employ] 7or su*     
cov]age (f]$ 9 connection ) su* a plan  
(f]$ by a specifi$ l>ge employ]7--  7i7 
a li/ ( drugs = :i* a claim 0 fil$ &1 ) 
respect to ea* su* drug on su* li/--    
7,i7 ! br& "n1 *emical entity1 &        
,national ,drug ,code2  7,,ii7 ! type ( 
disp5s+ *annel us$ to furni% su* drug1  
includ+ retail1 mail ord]1 or specialty 
ph>macy2  7,,iii7 ) respect to ea* drug 
disp5s$ "u ea* type ( disp5s+ *annel    
7includ+ retail1 mail ord]1 or specialty
 ph>macy7--  7aa7 :e!r su* drug is a br&
 "n drug or a g5]ic drug1 &-- 7,,aa7 9 !
 case ( a br& "n drug1 ! :olesale       
acquisition co/1 li/$ z co/ p] days     
supply & co/ p] dosage unit1 on ! date  
su* drug 0 disp5s$2 & 7,,bb7 9 ! case ( 
a g5]ic drug1 ! av]age :olesale price1  
li/$ z co/ p] days supply & co/ p]      
dosage unit1 on ! date su* drug 0       
disp5s$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7

 p>ticipants & b5efici>ies = :om a claim
 = su* drug 0 fil$2 7,,cc7 dosage units 
p] fill ( su* drug2 & 7,,dd7 days supply
 ( su* drug p] fill2  7,,iv7 ! net price
 p] c\rse ( treatm5t or s+le fill1 su* z
 a #cj-;day supply or #ij-;day supply to
 ! plan or cov]age aft] manufactur]     
rebates1 fees1 & o!r remun]ation or     
adju/m5ts2  7,v7 ! total am\nt (        
out-(-pocket sp5d+ by p>ticipants1      
b5efici>ies1 & enrollees on su* drug1   
includ+ sp5d+ ?r\gh copaym5ts1          
co9surance1 & d$uctibles2  7,,vi7 !     
total net sp5d+ by ! plan or cov]age    
dur+ ! report+ p]iod2  7,,vii7 ! total  
am\nt receiv$1 or expect$ to be receiv$1
 by ! plan or cov]age f any entity 9    
drug manufactur] rebates1 fees1         
alt]native disc\nts1 & all o!r          
remun]ation receiv$ f an entity or any  
?ird p>ty 7includ+ gr\p pur*as+         
organizations7 o!r ?an ! plan sponsor2  
7,,viii7 ! total am\nt receiv$1 or      
expect$ to be receiv$ by ! plan or      
issu]1 f drug manufactur]s 9 rebates1   

fees1 alt]native disc\nts1 or o!r       
remun]ation-- 7aa7 t has be5 paid1 or is
 to be paid1 by drug manufactur]s =     
claims incurr$ dur+ ! report+ p]iod2 &  
7bb7 t is relat$ to utilization rebates 
= su* drug2 &  7,,ix7 to ! ext5t        
feasible1 in=mation on ! total am\nt (  
remun]ation1 includ+ copaym5t assi/ance 
doll>s paid1 copaym5t c>ds appli$1 or   
o!r disc\nts provid$ by ea* drug        
manufactur] 7or entity adm9i/]+ copay   
assi/ance on behalf ( su* drug          
manufactur]7 to ! p>ticipants1          
b5efici>ies1 & enrollees enroll$ 9 su*  
plan or cov]age = su* drug2  7ii7 = ea* 
category or class ( drugs = :i* a claim 
0 fil$1 a breakd[n ( ! total gross sp5d+
 on drugs 9 su* category or class be=e  
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f drug     
manufactur]s1 & ! net sp5d+ aft] su*    
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f drug     
manufactur]s1 includ+-- 7,i7 ! numb] (  
p>ticipants1 b5efici>ies1 & enrollees :o

 fill$ a prescription = a drug 9 su*    
category or class1 includ+ ! ,national  
,drug ,code = ea* su* drug2  7,,ii7 if  
applicable1 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,,iii7 ! total out-(-pocket sp5d+ "u ! 
plan or cov]age by p>ticipants1         
b5efici>ies1 & enrollees1 includ+ sp5d+ 
?r\gh copaym5ts1 co9surance1 &          
d$uctibles2  7iii7 9 ! case ( a drug =  
:i* gross sp5d+ by su* plan1 cov]age1 or
 entity exce$$ #aj1jjj dur+ ! report+   
p]iod-- 7,i7 a li/ ( all o!r drugs 9 !  
same !rapeutic category or class2 &     
7,,ii7 ! rationale = ! =mul>y placem5t (
 su* drug 9 t !rapeutic category or     
class1 if applicable2 &  7iv7 9 ! case  
su* plan or cov]age 7or an entity       
provid+ ph>macy b5efits managem5t       
s]vices on behalf ( su* plan or cov]age7
 has an affiliat$ ph>macy or ph>macy "u 
common own]%ip--  7,i7 ! p]c5tage (     
total prescriptions disp5s$ by su*      

ph>macies to individuals enroll$ 9 su*  
plan or cov]age2  7,,ii7 a li/ ( all    
drugs disp5s$ by su* ph>macies to       
individuals enroll$ 9 su* plan or       
cov]age1 &1 ) respect to ea* drug       
disp5s$--  7aa7 ! am\nt *>g$1 p] dosage 
unit1 p] #cj-;day supply1 or p] #ij-;day
 supply 7z applicable7 to ! plan or     
issu]1 & to p>ticipants1 b5efici>ies1 & 
enrollees enroll$ 9 su* plan or cov]age2
  7bb7 ! m$ian am\nt *>g$ to su* plan or
 issu]1 & ! int]qu>tile range ( ! co/s1 
p] dosage unit1 p] #cj-;day supply1 & p]
 #ij-;day supply1 includ+ am\nts paid by
 ! p>ticipants1 b5efici>ies1 &          
enrollees1 :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  7cc7 ! l[e/ co/ p] dosage  
unit1 p] #cj-;day supply & p] #ij-;day  
supply1 = ea* su* drug1 includ+ am\nts  
*>g$ to ! plan & p>ticipants1           
b5efici>ies1 & enrollees1 t is available
 f any ph>macy includ$ 9 ! network ( su*

 plan or cov]age2 &  7dd7 ! net         
acquisition co/ p] dosage unit1 p]      
#cj-;day supply1 & p] #ij-;day supply1  
if su* drug is subject to a maximum     
price disc\nt2  7,b7 9 ! case ( a plan  
or cov]age n describ$ 9 subp>agraph     
7,a7-- 7i7 ! total net sp5d+ by ! plan  
or cov]age = all drugs cov]$ by su* plan
 or cov]age dur+ su* report+ p]iod2     
7ii7 ! total am\nt receiv$1 or expect$  
to be receiv$1 by ! plan or cov]age f   
any entity 9 drug manufactur] rebates1  
fees1 alt]native disc\nts1 & all o!r    
remun]ation receiv$ f an entity or any  
?ird p>ty 7includ+ gr\p pur*as+         
organizations7 o!r ?an ! plan sponsor = 
all su* drugs2 &  7iii7 to ! ext5t      
feasible1 in=mation on ! total am\nt (  
remun]ation1 includ+ copaym5t assi/ance 
doll>s paid1 copaym5t c>ds appli$1 or   
o!r disc\nts provid$ by ea* drug        
manufactur] 7or entity adm9i/]+ copay   
assi/ance on behalf ( su* drug          
manufactur]7 to ! p>ticipants1          
b5efici>ies1 & enrollees enroll$ 9 su*  

plan or cov]age = su* drugs2  7,c7      
am\nts paid directly or indirectly 9    
rebates1 fees1 or any o!r type (        
comp5sation 7z def9$ 9 section          
#djh7;b77#b77;,b77ii77dd77,,aa77 to     
brok]s1 consultants1 advisors1 or any   
o!r individual or firm1 = ! ref]ral ( ! 
gr\p heal? plan's or heal? insurance    
issu]'s bus9ess to an entity provid+    
ph>macy b5efits managem5t s]vices1      
includ+ ! id5tity ( ! recipi5t ( su*    
am\nts2  7,d7 an explanation ( any      
b5efit design p>amet]s t enc\rage or    
require p>ticipants1 b5efici>ies1 &     
enrollees 9 su* 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 directly or         
indirectly fund$ by su* entity2 &  7,e7 
total gross sp5d+ on all drugs dur+ !   

report+ p]iod4  7#c7 ,privacy           
requirem5ts  7,a7 ,9 g5]al ,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 #acdjb7;a7 ( ! ,heal? ,in=mation
 ,te*nology = ,cl9ical ,heal? ,act &    
consi/5t ) ! ,,hipaa privacy regulations
 7z def9$ 9 section #aahj7;b77#c7 ( !   
,social ,security ,act7 & %all re/rict !
 use & disclosure ( su* in=mation       
accord+ to su* privacy1 security1 &     
brea* notification regulations & su*    
,,hipaa privacy regulations4  7,b7      
,additional requirem5ts  7i7 ,9 g5]al   
,an entity provid+ ph>macy b5efits      
managem5t s]vices on behalf ( a gr\p    
heal? plan or heal? insurance issu] (f]+
 gr\p heal? insurance cov]age t submits 
a report "u p>agraph 7#a7 %all ensure t 
su* report conta9s only summ>y heal?    

in=mation1 z def9$ 9 section            
#afd4ejd7;a7 ( title #de1 ,code ( ,f$]al
 ,regulations 7or successor             
regulations74  7ii7 ,re/rictions ,a gr\p
 heal? plan %all comply ) section       
#afd4ejd7;f7 ( title #de1 ,code ( ,f$]al
 ,regulations 7or a successor           
regulation7 & a plan sponsor %all act 9 
accordance ) ! t]ms ( ! agreem5t        
describ$ 9 su* section4  7,c7 ,rule (   
con/ruction ,no?+ 9 ?is section %all be 
con/ru$ to modify ! requirem5ts = !     
creation1 receipt1 ma9t5ance1 or        
transmission ( protect$ heal? in=mation 
"u ! ,,hipaa privacy regulations 7z     
def9$ 9 section #aahj7;b77#c7 ( !       
,social ,security ,act74  7#d7          
,disclosure & r$isclosure  7,a7         
,limitation to bus9ess associates ,a    
gr\p heal? plan receiv+ a report "u     
p>agraph 7#a7 may disclose su* in=mation
 only to ! entity f :i* ! report 0      
receiv$ or to t entity's bus9ess        
associates z def9$ 9 section #afj4ajc ( 
title #de1 ,code ( ,f$]al ,regulations  

7or successor regulations7 or z p]mitt$ 
by ! ,,hipaa ,privacy ,rule 7#de ,,cfr  
p>ts #afj & #afd1 subp>ts ,a & ,e74     
7,b7 ,cl>ification reg>d+ public        
disclosure ( in=mation ,no?+ 9 ?is      
section %all prev5t 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 ( su* a plan or cov]age1 f plac+ 
reasonable re/rictions on ! public      
disclosure ( ! in=mation conta9$ 9 a    
report describ$ 9 p>agraph 7#a71 except 
t su* plan1 issu]1 or entity may n      
re/rict disclosure ( su* report to !    
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,dep>tm5t ( ,labor1 ! ,dep>tm5t ( !     
,treasury1 or ! ,comptroll] ,g5]al ( !  
,unit$ ,/ates4  7,c7 ,limit$ =m ( report
 ,! ,secret>y %all def9e ?r\gh rulemak+ 
a limit$ =m ( ! report "u p>agraph 7#a7 
requir$ ) respect to gr\p heal? plans   
:]e ! plan sponsors ( su* plans 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#e7 ,report to ,,gao ,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 ( su* plan  
or cov]age1 %all submit to ! ,comptroll]
 ,g5]al ( ! ,unit$ ,/ates ea* ( ! fir/  
#d reports submitt$ to a gr\p heal? plan
 "u p>agraph 7#a7 & o!r su* reports z   
reque/$1 9 accordance ) ! privacy       
requirem5ts "u p>agraph 7#c71 !         
disclosure & r$isclosure /&>ds "u       
p>agraph 7#d71 ! /&>ds specifi$ pursuant
 to p>agraph 7#f71 & su* o!r in=mation t
 ! ,comptroll] ,g5]al det]m9es necess>y 
to c>ry out ! /udy "u section #ajf7;d7 (
 ! ,l[] ,co/s1 ,m ,transp>5cy ,act4     
7#f7 ,/&>d =mat ,n lat] ?an #a ye> aft] 
! date ( enactm5t ( ?is section1 !      
,secret>y %all specify ?r\gh rulemak+   
/&>ds = gr\p heal? plans1 heal?         
insurance issu]s (f]+ gr\p heal?        
insurance cov]age1 & entities provid+   
ph>macy b5efits managem5t s]vices on    

behalf ( su* plans or cov]age1 requir$  
to submit reports "u p>agraph 7#a7 to   
submit su* reports 9 a /&>d =mat4  7c7  
,rule ( con/ruction ,no?+ 9 ?is section 
%all be con/ru$ to p]mit a gr\p heal?   
plan1 heal? insurance issu]1 or entity  
provid+ ph>macy b5efits managem5t       
s]vices on behalf ( su* plan or cov]age1
 to re/rict disclosure to1 or o!rwise   
limit ! access (1 ! ,secret>y ( ,labor  
to a report describ$ 9 subsection       
7b77#a7 or in=mation relat$ to          
compliance ) subsection 7a7 or 7b7 by   
entities subject to su* subsection4  7d7
 ,def9itions ,9 ?is section3  7#a7      
,specifi$ l>ge employ] ,! t]m specifi$  
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 9      
section #ejb 7#bi ,u4,s4,c4 #aacb7-- 7i7
 9 subsection 7b77#c71 by /rik+ "u      
subsection 7c77#i77 & ins]t+ "u         
p>agraphs 7#i7 & 7#ac7 ( subsection     
7c772 &  7ii7 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       
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  7c7 ,,irc  7#a7 ,9 g5]al   
,sub*apt] ,b ( *apt] #ajj ( ! ,int]nal  
,rev5ue ,code ( #aihf is am5d$ by add+  
at ! end ! foll[+3  #ihbf4 ,ov]sight (  
ph>macy b5efit manag] s]vices  7a7 ,9   
g5]al ,= plan ye>s beg9n+ on or aft] !  
date t is #b ye>s aft] ! date ( enactm5t
 ( ?is section1 a gr\p heal? plan1 or an
 entity or subsidi>y provid+ ph>macy    

b5efits managem5t s]vices on behalf (   
su* a plan1 %all n ent] into a contract 
) a drug manufactur]1 di/ributor1       
:olesal]1 subcontractor1 rebate         
aggregator1 or any o!r ?ird p>ty t      
limits 7or delays beyond ! applicable   
report+ p]iod describ$ 9 subsection     
7b77#a77 ! disclosure ( in=mation to    
gr\p heal? plans 9 su* a mann] t prev5ts
 su* plan or entity f mak+ ! reports    
describ$ 9 subsection 7b74  7b7 ,reports
  7#a7 ,9 g5]al ,) respect to plan ye>s 
beg9n+ on or aft] ! date t is #b ye>s   
aft] ! date ( enactm5t ( ?is section1 n 
less frequ5tly ?an e #f mon?s 7or at !  
reque/ ( a gr\p heal? plan1 n less      
frequ5tly ?an qu>t]ly1 b "u ! same      
conditions1 t]ms1 & co/ ( ! semiannual  
report "u ?is subsection71 a gr\p heal? 
plan1 or an entity provid+ ph>macy      
b5efits managem5t s]vices on behalf (   
su* a plan1 %all submit to ! gr\p heal? 
plan a report 9 accordance ) ?is        
section4 ,ea* su* report %all be made   
available to su* gr\p heal? plan 9 a    

ma*9e-readable =mat & %all include !    
in=mation describ$ 9 p>agraph 7#b74     
7#b7 ,in=mation describ$ ,= purposes (  
p>agraph 7#a71 ! in=mation describ$ 9   
?is p>agraph is1 ) respect to drugs     
cov]$ by a gr\p heal? plan dur+ ea*     
report+ p]iod-- 7,a7 9 ! case ( su* a   
plan (f]$ by a specifi$ l>ge employ]--  
7i7 a li/ ( drugs = :i* a claim 0 fil$  
&1 ) respect to ea* su* drug on su*     
li/-- 7,i7 ! br& "n1 *emical entity1 &  
,national ,drug ,code2  7,,ii7 ! type ( 
disp5s+ *annel us$ to furni% su* drug1  
includ+ retail1 mail ord]1 or specialty 
ph>macy2  7,,iii7 ) respect to ea* drug 
disp5s$ "u ea* type ( disp5s+ *annel    
7includ+ retail1 mail ord]1 or specialty
 ph>macy7--  7aa7 :e!r su* drug is a br&
 "n drug or a g5]ic drug1 &-- 7,,aa7 9 !
 case ( a br& "n drug1 ! :olesale       
acquisition co/1 li/$ z co/ p] days     
supply & co/ p] dosage unit1 on ! date  
su* drug 0 disp5s$2 & 7,,bb7 9 ! case ( 
a g5]ic drug1 ! av]age :olesale price1  
li/$ z co/ p] days supply & co/ p]      

dosage unit1 on ! date su* drug 0       
disp5s$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7
 p>ticipants1 b5efici>ies1 & enrollees =
 :om a claim = su* drug 0 fil$2 7,,cc7  
dosage units p] fill ( su* drug2 &      
7,,dd7 days supply ( su* drug p] fill2  
7,,iv7 ! net price p] c\rse ( treatm5t  
or s+le fill1 su* z a #cj-;day supply or
 #ij-;day supply to ! plan aft]         
manufactur] rebates1 fees1 & o!r        
remun]ation or adju/m5ts2  7,v7 ! total 
am\nt ( out-(-pocket sp5d+ by           
p>ticipants1 b5efici>ies1 & enrollees on
 su* drug1 includ+ sp5d+ ?r\gh          
copaym5ts1 co9surance1 & d$uctibles2    
7,,vi7 ! total net sp5d+ by ! plan dur+ 
! report+ p]iod2  7,,vii7 ! total am\nt 
receiv$1 or expect$ to be receiv$1 by ! 
plan f any entity 9 drug manufactur]    
rebates1 fees1 alt]native disc\nts1 &   
all o!r remun]ation receiv$ f an entity 
or any ?ird p>ty 7includ+ gr\p pur*as+  
organizations7 o!r ?an ! plan sponsor2  

7,,viii7 ! total am\nt receiv$1 or      
expect$ to be receiv$ by ! plan1 f drug 
manufactur]s 9 rebates1 fees1 alt]native
 disc\nts1 or o!r remun]ation-- 7aa7 t  
has be5 paid1 or is to be paid1 by drug 
manufactur]s = claims incurr$ dur+ !    
report+ p]iod2 &  7bb7 t is relat$ to   
utilization rebates = su* drug2 &       
7,,ix7 to ! ext5t feasible1 in=mation on
 ! total am\nt ( remun]ation1 includ+   
copaym5t assi/ance doll>s paid1 copaym5t
 c>ds appli$1 or o!r disc\nts provid$ by
 ea* drug manufactur] 7or entity        
adm9i/]+ copay assi/ance on behalf ( su*
 drug manufactur]7 to ! p>ticipants1    
b5efici>ies1 & enrollees enroll$ 9 su*  
plan = su* drug2  7ii7 = ea* category or
 class ( drugs = :i* a claim 0 fil$1 a  
breakd[n ( ! total gross sp5d+ on drugs 
9 su* category or class be=e rebates1   
price concessions1 alt]native disc\nts1 
or o!r remun]ation f drug manufactur]s1 
& ! net sp5d+ aft] su* rebates1 price   
concessions1 alt]native disc\nts1 or o!r
 remun]ation f drug manufactur]s1       

includ+-- 7,i7 ! numb] ( p>ticipants1   
b5efici>ies1 & enrollees :o fill$ a     
prescription = a drug 9 su* category or 
class1 includ+ ! ,national ,drug ,code =
 ea* su* drug2  7,,ii7 if applicable1 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,,iii7 ! 
total out-(-pocket sp5d+ "u ! plan by   
p>ticipants1 b5efici>ies1 & enrollees1  
includ+ sp5d+ ?r\gh copaym5ts1          
co9surance1 & d$uctibles2 &  7iii7 9 !  
case ( a drug = :i* gross sp5d+ by su*  
plan or entity exce$$ #aj1jjj dur+ !    
report+ p]iod-- 7,i7 a li/ ( all o!r    
drugs 9 ! same !rapeutic category or    
class2 &  7,,ii7 ! rationale = ! =mul>y 
placem5t ( su* drug 9 t !rapeutic       
category or class1 if applicable2 &     
7iv7 9 ! case su* plan 7or an entity    
provid+ ph>macy b5efits managem5t       
s]vices on behalf ( su* plan7 t has an  
affiliat$ ph>macy or ph>macy "u common  
own]%ip--  7,i7 ! p]c5tage ( total      

prescriptions disp5s$ by su* ph>macies  
to individuals enroll$ 9 su* plan2      
7,,ii7 a li/ ( all drugs disp5s$ by su* 
ph>macies to individuals enroll$ 9 su*  
plan1 &1 ) respect to ea* drug disp5s$--
  7aa7 ! am\nt *>g$1 p] dosage unit1 p] 
#cj-;day supply1 or p] #ij-;day supply  
7z applicable7 to ! plan1 & to          
p>ticipants1 b5efici>ies1 & enrollees   
enroll$ 9 su* plan2  7bb7 ! m$ian am\nt 
*>g$ to su* plan1 & ! int]qu>tile range 
( ! co/s1 p] dosage unit1 p] #cj-;day   
supply1 & p] #ij-;day supply1 includ+   
am\nts paid by ! p>ticipants1           
b5efici>ies1 & enrollees1 :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  7cc7 ! l[e/ co/ p] 
dosage unit1 p] #cj-;day supply & p]    
#ij-;day supply1 = ea* su* drug1 includ+
 am\nts *>g$ to ! plan & p>ticipants1   
b5efici>ies1 & enrollees1 t is available
 f any ph>macy includ$ 9 ! network ( su*
 plan2 &  7dd7 ! net acquisition co/ p] 

dosage unit1 p] #cj-;day supply1 & p]   
#ij-;day supply1 if su* drug is subject 
to a maximum price disc\nt2  7,b7 9 !   
case ( a plan n describ$ 9 subp>agraph  
7,a7-- 7i7 ! total net sp5d+ by ! plan =
 all drugs cov]$ by su* plan dur+ su*   
report+ p]iod2  7ii7 ! total am\nt      
receiv$1 or expect$ to be receiv$1 by ! 
plan f any entity 9 drug manufactur]    
rebates1 fees1 alt]native disc\nts1 &   
all o!r remun]ation receiv$ f an entity 
or any ?ird p>ty 7includ+ gr\p pur*as+  
organizations7 o!r ?an ! plan sponsor = 
all su* drugs2 &  7iii7 to ! ext5t      
feasible1 in=mation on ! total am\nt (  
remun]ation1 includ+ copaym5t assi/ance 
doll>s paid1 copaym5t c>ds appli$1 or   
o!r disc\nts provid$ by ea* drug        
manufactur] 7or entity adm9i/]+ copay   
assi/ance on behalf ( su* drug          
manufactur]7 to ! p>ticipants1          
b5efici>ies1 & enrollees enroll$ 9 su*  
plan = su* drugs2  7,c7 am\nts paid     
directly or indirectly 9 rebates1 fees1 
or any o!r type ( comp5sation 7z def9$ 9

 section #djh7;b77#b77;,b77ii77dd77,,aa7
 ( ! ,employee ,retirem5t ,income       
,security ,act7 to brok]s1 consultants1 
advisors1 or any o!r individual or firm1
 = ! ref]ral ( ! gr\p heal? plan's      
bus9ess to an entity provid+ ph>macy    
b5efits managem5t s]vices1 includ+ !    
id5tity ( ! recipi5t ( su* am\nts2  7,d7
 an explanation ( any b5efit design     
p>amet]s t enc\rage or require          
p>ticipants1 b5efici>ies1 & enrollees 9 
su* 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 directly or 
indirectly fund$ by su* entity2 &  7,e7 
total gross sp5d+ on all drugs dur+ !   
report+ p]iod4  7#c7 ,privacy           
requirem5ts  7,a7 ,9 g5]al ,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       
#acdjb7;a7 ( ! ,heal? ,in=mation        
,te*nology = ,cl9ical ,heal? ,act &     
consi/5t ) ! ,,hipaa privacy regulations
 7z def9$ 9 section #aahj7;b77#c7 ( !   
,social ,security ,act7 & %all re/rict !
 use & disclosure ( su* in=mation       
accord+ to su* privacy1 security1 &     
brea* notification regulations & su*    
,,hipaa privacy regulations4  7,b7      
,additional requirem5ts  7i7 ,9 g5]al   
,an entity provid+ ph>macy b5efits      
managem5t s]vices on behalf ( a gr\p    
heal? plan t submits a report "u        
p>agraph 7#a7 %all ensure t su* report  
conta9s only summ>y heal? in=mation1 z  
def9$ 9 section #afd4ejd7;a7 ( title    
#de1 ,code ( ,f$]al ,regulations 7or    
successor regulations74  7ii7           
,re/rictions ,a gr\p heal? plan %all    
comply ) section #afd4ejd7;f7 ( title   
#de1 ,code ( ,f$]al ,regulations 7or a  

successor regulation7 & a plan sponsor  
%all act 9 accordance ) ! t]ms ( !      
agreem5t describ$ 9 su* section4  7,c7  
,rule ( con/ruction ,no?+ 9 ?is section 
%all be con/ru$ to modify ! requirem5ts 
= ! creation1 receipt1 ma9t5ance1 or    
transmission ( protect$ heal? in=mation 
"u ! ,,hipaa privacy regulations 7z     
def9$ 9 section #aahj7;b77#c7 ( !       
,social ,security ,act74  7#d7          
,disclosure & r$isclosure  7,a7         
,limitation to bus9ess associates ,a    
gr\p heal? plan receiv+ a report "u     
p>agraph 7#a7 may disclose su* in=mation
 only to ! entity f :i* ! report 0      
receiv$ or to t entity's bus9ess        
associates z def9$ 9 section #afj4ajc ( 
title #de1 ,code ( ,f$]al ,regulations  
7or successor regulations7 or z p]mitt$ 
by ! ,,hipaa ,privacy ,rule 7#de ,,cfr  
p>ts #afj & #afd1 subp>ts ,a & ,e74     
7,b7 ,cl>ification reg>d+ public        
disclosure ( in=mation ,no?+ 9 ?is      
section %all prev5t 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 ( su* a plan or cov]age1 f plac+ 
reasonable re/rictions on ! public      
disclosure ( ! in=mation conta9$ 9 a    
report describ$ 9 p>agraph 7#a71 except 
t su* plan1 issu]1 or entity may n      
re/rict disclosure ( su* report to !    
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,dep>tm5t ( ,labor1 ! ,dep>tm5t ( !     
,treasury1 or ! ,comptroll] ,g5]al ( !  
,unit$ ,/ates4  7,c7 ,limit$ =m ( report
 ,! ,secret>y %all def9e ?r\gh rulemak+ 
a limit$ =m ( ! report "u p>agraph 7#a7 
requir$ ) respect to gr\p heal? plans   
:]e ! plan sponsors ( su* plans 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#e7 ,report to ,,gao ,a gr\p
 heal? plan1 or an entity provid+       
ph>macy b5efits managem5t s]vices on    
behalf ( su* plan1 %all submit to !     
,comptroll] ,g5]al ( ! ,unit$ ,/ates ea*
 ( ! fir/ #d reports submitt$ to a gr\p 

heal? plan "u p>agraph 7#a7 & o!r su*   
reports z reque/$1 9 accordance ) !     
privacy requirem5ts "u p>agraph 7#c71 ! 
disclosure & r$isclosure /&>ds "u       
p>agraph 7#d71 ! /&>ds specifi$ pursuant
 to p>agraph 7#f71 & su* o!r in=mation t
 ! ,comptroll] ,g5]al det]m9es necess>y 
to c>ry out ! /udy "u section #ajf7;d7 (
 ! ,l[] ,co/s1 ,m ,transp>5cy ,act4     
7#f7 ,/&>d =mat ,n lat] ?an #a ye> aft] 
! date ( enactm5t ( ?is section1 !      
,secret>y %all specify ?r\gh rulemak+   
/&>ds = gr\p heal? plans1 & entities    
provid+ ph>macy b5efits managem5t       
s]vices on behalf ( su* plans1 requir$  
to submit reports "u p>agraph 7#a7 to   
submit su* reports 9 a /&>d =mat4  7c7  
,rule ( con/ruction ,no?+ 9 ?is section 
%all be con/ru$ to p]mit a gr\p heal?   
plan or entity provid+ ph>macy b5efits  
managem5t s]vices on behalf ( su* plan1 
to re/rict disclosure to1 or o!rwise    
limit ! access (1 ! ,secret>y ( ,heal? &
 ,human ,s]vices to a report describ$ 9 
subsection 7b77#a7 or in=mation relat$  

to compliance ) subsections 7a7 or 7b7  
by entities subject to su* subsection4  
7d7 ,def9itions ,9 ?is section3  7#a7   
,specifi$ l>ge employ] ,! t]m specifi$  
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  7d7 ,,gao reports   
7#a7 ,report on ph>macy network design  
7,a7 ,9 g5]al ,n lat] ?an #c ye>s aft] !
 date ( enactm5t ( ?is ,act1 !          
,comptroll] ,g5]al ( ! ,unit$ ,/ates    

%all submit to ,congress a report on--  
7i7 ph>macy networks t h contract$ )    
gr\p heal? plans1 heal? insurance issu]s
 (f]+ gr\p heal? insurance cov]age1 or  
entities provid+ ph>macy b5efits        
managem5t s]vices on behalf ( su* plans 
or issu]s1 includ+ networks ) ph>macies 
t are "u common own]%ip 79 :ole or "p7 )
 su* plans1 issu]s1 or entities 7includ+
 entities t provide ph>macy b5efits     
adm9i/rative s]vices on behalf ( su*    
plans or issu]s72  7ii7 ph>macy network 
design p>amet]s t enc\rage individuals  
enroll$ 9 su* plans or cov]age to fill  
prescriptions at mail ord]1 specialty1  
or retail ph>macies t are :olly or      
p>tially own$ by a plan1 issu]1 or      
entity2  7iii7 :e!r su* plans & issu]s h
 options to elect diff]5t network pric+ 
arrangem5ts 9 ! m>ketplace ) entities t 
provide ph>macy b5efits managem5t       
s]vices & ! preval5ce ( elect+ su*      
diff]5t network pric+ arrangem5ts2  7iv7
 ) respect to ph>macy networks t include
 ph>macies "u common own]%ip describ$ 9 

clause 7i7--  7,i7 :e!r su* networks are
 design$ to enc\rage individuals enroll$
 9 a gr\p heal? plan or heal? insurance 
cov]age to use su* ph>macies ov] o!r    
network ph>macies = specific s]vices or 
drugs1 & if s1 ! reasons ! networks give
 = enc\rag+ use ( su* ph>macies2 &      
7,,ii7 :e!r su* ph>macies are us$ by    
enrollees disproportionately m 9 !      
aggregate or = specific s]vices or drugs
 comp>$ to o!r network ph>macies2  7v7 !
 degree to :i* mail ord]1 specialty1 or 
retail ph>macies t disp5se prescription 
drugs to an enrollee 9 a plan or cov]age
 t are "u common own]%ip 79 :ole or "p7 
) plans1 issu]s1 or entities provid+    
ph>macy b5efits managem5t s]vices or    
ph>macy b5efits adm9i/rative s]vices on 
behalf ( su* plan or cov]age receive    
reimbursem5t t is great] ?an ! m$ian    
price *>g$ to ! plan or issu] :5 ! same 
drug is disp5s$ to enrollees 9 ! plan or
 cov]age by o!r ph>macies includ$ 9 !   
ph>macy network ( t plan1 issu]1 or     
entity t are n :olly or p>tially own$ by

 ! plan or issu]1 or entity provid+     
ph>macy b5efits managem5t s]vices on    
behalf ( su* plan or issu]4  7,b7       
,requirem5t ,! ,comptroll] ,g5]al ( !   
,unit$ ,/ates %all ensure t ! report "u 
subp>agraph 7,a7 does n conta9 in=mation
 t w\ld id5tify a specific gr\p heal?   
plan or heal? insurance issu] 7or an    
entity provid+ ph>macy b5efits managem5t
 s]vices on behalf ( su* plan or issu]71
 or o!rwise conta9 comm]cial or f9ancial
 in=mation t is privileg$ or            
confid5tial4  7,c7 ,def9itions ,9 ?is   
p>agraph1 ! t]ms gr\p heal? plan1 heal? 
insurance cov]age1 & heal? insurance    
issu] h ! mean+s giv5 su* t]ms 9 section
 #bgia ( ! ,public ,heal? ,s]vice ,act  
7#db ,u4,s4,c4 #cjj;gg-#ia74  7#b7      
,report on copay assi/ance programs ,n  
lat] ?an #ah mon?s aft] ! date ( !      
enactm5t ( ?is ,act1 ! ,comptroll]      
,g5]al ( ! ,unit$ ,/ates %all submit to 
,congress a report on :at is kn[n ab\t !
 role ( copay assi/ance programs & !    
impact ( su* programs on comm]cial heal?

 insurance1 /op loss1 & drug prices4    
,su* report %all include to ! ext5t     
feasible--  7,a7 a description ( copay  
assi/ance programs1 includ+-- 7i7 !     
types ( programs available & ! me?ods ( 
provid+ copay assi/ance ?r\gh su*       
programs1 includ+ ca% disc\nts1 copay   
c>ds1 or drugs provid$ to an individual 
at no co/2  7ii7 h[ su* programs are    
fund$2  7iii7 ! types ( entities t own1 
op]ate1 or o!rwise conduct su* programs1
 ! types ( in=mation su* entities       
collect1 & ! direct & indirect          
contractual relation%ips betwe5 !       
entities 9 ! drug supply *a9 t int]act )
 su* programs1 su* z a drug manufactur]1
 ph>macy1 :olesal]1 swit*1 rebate       
aggregator1 ph>macy b5efit manag]1 & o!r
 entities 9 ! drug supply *a92  7iv7 !  
effect ( su* programs on pati5t         
out-(-pocket sp5d+1 includ+ = /op-loss  
insurance1 & drug utilization1 includ+  
drug adh]5ce2 &  7v7 pati5t eligibility 
crit]ia = su* programs2 &  7,b7 an      
analysis (-- 7i7 ! s\rces ( fund+ = su* 

programs2 &  7ii7 ! effects ( su*       
programs on ,f$]al heal? c>e programs & 
! individuals enroll$ 9 su* ,f$]al heal?
 c>e programs4  #ajg4 ,reports on heal? 
c>e transp>5cy tools & data  7a7        
,initial report ,n lat] ?an ,decemb]    
#ca1 #bjbd1 ! ,comptroll] ,g5]al ( !    
,unit$ ,/ates %all submit to !          
,committees 7z def9$ 9 subsection 7d77  
an initial report t--  7#a7 id5tifies & 
describes heal? c>e transp>5cy tools &  
,f$]al heal? c>e report+ requirem5ts 7z 
describ$ 9 subsection 7d77 t are 9      
effect z ( ! date ( ! submission ( su*  
initial report1 includ+ ! frequ5cy (    
reports ) respect to ea* su* requirem5t 
& :e!r any su* requirem5ts are          
duplicative2  7#b7 reviews h[ su*       
report+ requirem5ts are en=c$2  7#c7    
analyzes :e!r ! public availability (   
heal? c>e transp>5cy tools1 & !         
publication ( data pursuant to su*      
report+ requirem5ts1 has-- 7,a7 be5     
utiliz$ & valu$ by consum]s1 includ+    
reasons = su* utilization 7or lack      

!re(72 &  7,b7 assi/$ heal? insurance   
plan sponsors & fiduci>ies improve      
b5efits1 l[] heal? c>e co/s = plan      
p>ticipants1 & meet fiduci>y            
requirem5ts2  7#d7 includes             
recomm5dations to ! ,committees1 !      
,secret>y ( ,heal? & ,human ,s]vices1 ! 
,secret>y ( ,labor1 & ! ,secret>y ( !   
,treasury to--  7,a7 improve !          
effici5cy1 accuracy1 & usability ( heal?
 c>e transp>5cy tools2  7,b7 /reaml9e   
,f$]al heal? c>e report+ requirem5ts to 
elim9ate duplicative requirem5ts & r$uce
 ! burd5 on entities requir$ to submit  
reports pursuant to su* provisions2     
7,c7 improve ! accuracy & effici5cy (   
su* reports :ile ma9ta9+ ! integrity &  
usability ( ! data provid$ by su*       
reports2  7,d7 address any gaps 9 data  
provid$ by su* reports2 &  7,e7 ensure t
 ! data & in=mation report$ is comp>able
 & usable to consum]s1 includ+ pati5ts1 
plan sponsors1 & policy mak]s4  7b7     
,f9al report ,n lat] ?an ,decemb] #ca1  
#bjbh1 ! ,comptroll] ,g5]al ( ! ,unit$  

,/ates %all submit to ! ,committees a   
report t includes--  7#a7 ! in=mation   
provid$ 9 ! initial report1 along ) any 
updates to su* in=mation2 &  7#b7 any   
new in=mation ) respect to heal? c>e    
transp>5cy tools t h be5 releas$ foll[+ 
! submission ( su* initial report1 or   
new report+ requirem5ts 9 effect z ( !  
date ( ! submission ( ! f9al report4    
7c7 ,report on exp&+ price transp>5cy   
requirem5ts ,n lat] ?an ,decemb] #ca1   
#bjbe1 ! ,comptroll] ,g5]al ( ! ,unit$  
,/ates1 9 consultation ) ! ,secret>y (  
,heal? & ,human ,s]vices1 heal? c>e     
provid] gr\ps1 & pati5t advocacy gr\ps1 
%all submit to ! ,committees a report t 
includes recomm5dations to exp& price   
transp>5cy report+ requirem5ts to       
additional c>e sett+s1 ) an emphasis on 
sett+s :]e %oppable s]vices 7z def9$ 9  
subsection 7d77 are furni%$4  7d7       
,def9itions ,9 ?is section3  7#a7       
,committees ,! t]m ,committees means !  
,committee on ,ways & ,means1 !         
,committee on ,en]gy & ,comm]ce1 & !    

,committee on ,education & ! ,work=ce ( 
! ,h\se ( ,repres5tatives1 & !          
,committee on ,f9ance & ! ,committee on 
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate4  7#b7 ,f$]al heal? c>e       
report+ requirem5ts ,! t]m ,f$]al heal? 
c>e report+ requirem5ts includes        
regulatory & /atutory requirem5ts )     
respect to ! report+ & publication (    
heal? c>e price1 co/ access1 & quality  
data1 includ+ requirem5ts e/abli%$ by ! 
,consolidat$ ,appropriations ,act (     
#bjba 7,public ,law #aaf-bfj71 ?is ,act1
 & o!r report+ & publication requirem5ts
 ) respect to transp>5cy 9 heal? c>e z  
id5tifi$ by ! ,comptroll] ,g5]al ( !    
,unit$ ,/ates4  7#c7 ,%oppable s]vice ,!
 t]m %oppable s]vice means a s]vice t c 
be s*$ul$ by a heal? c>e consum] 9      
advance & includes all ancill>y items & 
s]vices cu/om>ily furni%$ z "p ( su*    
s]vice4  #ajh4 ,report on integration 9 
,m$ic>e  7a7 ,requir$ ,,ma & ,,pdp      
report+  7#a7 ,,ma plans ,section       
#aheg7;e7 ( ! ,social ,security ,act    

7#db ,u4,s4,c4 #aciew-#bg7;e77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#f7 ,requir$ disclosure ( c]ta9        
in=mation relat+ to heal? c>e provid]   
own]%ip  7,a7 ,9 g5]al ,= plan ye> #bjbe
 & = e ?ird plan ye> !reaft]1 ea*       
applicable ,,ma organization (f]+ an    
,,ma plan "u ?is "p dur+ su* plan ye>   
%all submit to ! ,secret>y1 at a "t & 9 
a mann] specifi$ by ! ,secret>y-- 7i7 ! 
taxpay] id5tification numb] = ea* heal? 
c>e provid] t 0 a specifi$ heal? c>e    
provid] ) respect to su* organization   
dur+ su* ye>2  7ii7 ! total am\nt (     
inc5tive-bas$ paym5ts made to1 & ! total
 am\nt ( %>$ losses rec\pm5ts collect$  
f1 su* specifi$ heal? c>e provid]s dur+ 
su* plan ye>2 &  7iii7 ! total am\nt (  
inc5tive-bas$ paym5ts made to1 & ! total
 am\nt ( %>$ losses rec\pm5ts collect$  
f1 provid]s ( s]vices & suppli]s n      
describ$ 9 clause 7ii7 dur+ su* plan    
ye>4  7,b7 ,def9itions ,= purposes ( ?is
 p>agraph3 7i7 ,applicable ,,ma         
organization ,! t]m applicable ,,ma     

organization means1 ) respect to a plan 
ye>1 an ,,ma organization ) at lea/     
#be1jjj individuals enroll$ "u ,m$ic>e  
,advantage plans (f]$ by su*            
organization dur+ su* plan ye>4  7ii7   
,specifi$ heal? c>e provid] ,! t]m      
specifi$ heal? c>e provid] means1 )     
respect to an applicable ,,ma           
organization & a plan ye>1 a provid] (  
s]vices or suppli] ) respect to :i* su* 
organization 7or any p]son ) an own]%ip 
or control int]e/ 7z def9$ 9 section    
#aabd7;a77#c77 9 su* organization7 is a 
p]son ) an own]%ip or control int]e/ 7z 
s def9$74  4  7#b7 ,prescription drug   
plans ,section #ahfj;,d-#ab7;b7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#aab7;b77 is am5d$ by add+ at !  
end ! foll[+ new p>agraph3  7#i7        
,provision ( in=mation relat+ to ph>macy
 own]%ip  7,a7 ,9 g5]al ,= plan ye>     
#bjbe & = e ?ird plan ye> !reaft]1 ea*  
,,pdp sponsor (f]+ a prescription drug  
plan "u ?is "p dur+ su* plan ye> %all   
submit to ! ,secret>y1 at a "t & 9 a    

mann] specifi$ by ! ,secret>y1 ! taxpay]
 id5tification numb] & ,national        
,provid] ,id5tifi] = ea* ph>macy t 0 a  
specifi$ ph>macy ) respect to su*       
sponsor dur+ su* ye>4  7,b7 ,def9ition  
,= purposes ( ?is p>agraph1 ! t]m       
specifi$ ph>macy means1 ) respect to an 
,,pdp sponsor (f]+ a prescription drug  
plan & a plan ye>1 a ph>macy ) respect  
to :i*--  7i7 su* sponsor 7or any p]son 
) an own]%ip or control int]e/ 7z def9$ 
9 section #aabd7;a77#c77 9 su* sponsor7 
is a p]son ) an own]%ip or control      
int]e/ 7z s def9$72 or  7ii7 a ph>macy  
b5efit manag] (f]+ s]vices "u su* plan  
7or any p]son ) an own]%ip or control   
int]e/ 7z s def9$7 9 su* sponsor7 is a  
p]son ) an own]%ip or control int]e/ 7z 
s def9$74  4  7b7 ,med,p,a,c reports ,"p
 ,e ( title ,,xviii ( ! ,social         
,security ,act 7#db ,u4,s4,c4 #aciex et 
seq471 z am5d$ by section #aja1 is fur!r
 am5d$ by add+ at ! end ! foll[+ new    
section3  #ahii;,d4 ,reports on v]tical 
integration "u ,m$ic>e  7a7 ,9 g5]al ,n 

lat] ?an ,june #ae1 #bjbi1 & e #c ye>s  
!reaft]1 ! ,m$ic>e ,paym5t ,advisory    
,commission %all submit to ,congress a  
report on ! /ate ( v]tical integration 9
 ! heal? c>e sector dur+ ! applicable   
ye> ) respect to entities p>ticipat+ 9 !
 ,m$ic>e program1 includ+ heal? c>e     
provid]s1 ph>macies1 prescription drug  
plan sponsors1 ,m$ic>e ,advantage       
organizations1 & ph>macy b5efit manag]s4
 ,su* report %all include--  7#a7 )     
respect to ,m$ic>e ,advantage           
organizations1 ! evaluation describ$ 9  
subsection 7b72  7#b7 ) respect to      
prescription drug plans1 ph>macy b5efit 
manag]s1 & ph>macies1 ! comp>isons &    
evaluations describ$ 9 subsection 7c72  
7#c7 ) respect to ,m$ic>e ,advantage    
plans "u :i* b5efits are available =    
physician-adm9i/]$ drugs1 ! in=mation   
describ$ 9 subsection 7d72  7#d7 !      
id5tifications describ$ 9 subsection    
7e72 &  7#e7 an analysis ( ! impact (   
su* integration on heal? c>e access1    
price1 quality1 & outcomes4  7b7 ,m$ic>e

 ,advantage organizations ,= purposes ( 
subsection 7a77#a71 ! evaluation        
describ$ 9 ?is subsection is1 ) respect 
to ,m$ic>e ,advantage organizations & an
 applicable ye>1 an evaluation1 tak+    
into acc\nt pati5t acuity & ! types (   
areas s]vic$ by su* organization1 (--   
7#a7 ! av]age numb] ( qualify+ diagnoses
 made dur+ su* ye> ) respect to         
enrollees ( a ,m$ic>e ,advantage plan   
(f]$ by su* organization :o1 dur+ su*   
ye>1 receiv$ a heal? risk assessm5t f a 
specifi$ heal? c>e provid]2  7#b7 !     
av]age risk score = su* enrollees :o    
receiv$ su* an assessm5t dur+ su* ye>2  
7#c7 any relation%ip betwe5 su* risk    
scores = su* enrollees receiv+ su* an   
assessm5t f su* a provid] dur+ su* ye> &
 inc5tive paym5ts made to su* provid]s2 
7#d7 ! av]age risk score = enrollees (  
su* plan :o receiv$ any item or s]vice f
 a specifi$ heal? c>e provid] dur+ su*  
ye>2  7#e7 any relation%ip betwe5 ! risk
 scores ( enrollees "u su* plan & :e!r !
 enrollees h receiv$ any item or s]vice 

f a specifi$ provid]2 &  7#f7 any       
relation%ip betwe5 ! risk scores (      
enrollees "u su* plan t h receiv$ any   
item or s]vice f a specifi$ provid] &   
inc5tive paym5ts made "u ! plan to      
specifi$ provid]s4  7c7 ,prescription   
drug plans ,= purposes ( subsection     
7a77#b71 ! comp>isons & evaluations     
describ$ 9 ?is subsection are1 ) respect
 to prescription drug plans & an        
applicable ye>1 ! foll[+3 7#a7 ,= ea*   
cov]$ "p ,d drug = :i* b5efits are      
available "u su* a plan1 a comp>ison ( !
 av]age negotiat$ rate 9 effect )       
specifi$ ph>macies ) su* rates 9 effect 
= 9-network ph>macies t are n specifi$  
ph>macies4  7#b7 ,comp>isons ( ! foll[+3
 7,a7 ,! total am\nt paid by ph>macy    
b5efit manag]s to specifi$ ph>macies =  
cov]$ "p ,d drugs & ! total am\nt s paid
 to ph>macies t are n specifi$ ph>macies
 = su* drugs4  7,b7 ,! total am\nt paid 
by su* sponsors to specifi$ ph>macy     
b5efit manag]s z reimbursem5t = cov]$ "p
 ,d drugs & ! total am\nt s paid to     

ph>macy b5efit manag]s t are n specifi$ 
ph>macy b5efit manag]s z su*            
reimbursem5t4  7,c7 ,fees paid "u by    
plan to specifi$ ph>macy b5efit manag]s 
comp>$ to su* fees paid to ph>macy      
b5efit manag]s t are n specifi$ ph>macy 
b5efit manag]s4  7#c7 ,an evaluation ( !
 total am\nt ( direct & indirect        
remun]ation = cov]$ "p ,d drugs pass$   
?r\gh to prescription drug plan sponsors
 & ! total am\nt reta9$ by ph>macy      
b5efit manag]s 7includ+ entities "u     
contract ) su* a manag]74  7#d7 ,to !   
ext5t t ! available data p]mits1 an     
evaluation ( fees *>g$ by rebate        
aggregators t are affiliat$ ) plan      
sponsors4  7d7 ,physician-adm9i/]$ drugs
 ,= purposes ( subsection 7a77#c71 !    
in=mation describ$ 9 ?is subsection is1 
) respect to physician-adm9i/]$ drugs = 
:i* b5efits are available "u a ,m$ic>e  
,advantage plan dur+ an applicable ye>1 
! foll[+3 7#a7 ,) respect to ea* su*    
plan1 an id5tification ( ea* drug = :i* 
b5efits 7 available "u su* plan only :5 

adm9i/]$ by a heal? c>e provid] t       
acquir$ su* drug f an affiliat$ ph>macy4
  7#b7 ,an evaluation ( ! diff]5ce      
betwe5 ! total numb] ( drugs adm9i/]$ by
 a heal? c>e provid] t 7 acquir$ f      
affiliat$ ph>macies comp>$ to ! numb] ( 
su* drugs s adm9i/]$ t 7 acquir$ f      
ph>macies o!r ?an affiliat$ ph>macies1 &
 an evaluation ( ! diff]5ce 9 paym5ts = 
su* drugs s adm9i/]$ :5 acquir$ f a     
specifi$ ph>macy & :5 acquir$ f a       
ph>macy t is n a specifi$ ph>macy4  7#c7
 ,an evaluation ( ! doll> value ( all   
su* drugs t 7 n s adm9i/]$ because ( a  
delay attributable to an affiliat$      
ph>macy comp>$ to ! doll> value ( all   
su* drugs t 7 n s adm9i/]$ because ( a  
delay attributable to ph>macy t is n an 
affiliat$ ph>macy4  7#d7 ,! numb] (     
enrollees adm9i/]$ su* a drug t 0       
acquir$ f an affiliat$ ph>macy4  7#e7 ,!
 numb] ( enrollees furni%$ su* a drug t 
0 acquir$ f a ph>macy t is n an         
affiliat$ ph>macy4  7e7 ,id5tifications 
,= purposes ( subsection 7a77#d71 !     

id5tifications describ$ 9 ?is subsection
 are1 ) respect to an applicable ye>1   
id5tifications ( ea* heal? c>e entity   
p>ticipat+ "u ! ,m$ic>e program )       
respect to :i* ano!r heal? c>e entity s 
p>ticipat+ is a p]son ) an own]%ip or   
control int]e/ 7z def9$ 9 section       
#aabd7;a77#c774  7f7 ,def9itions ,9 ?is 
section3  7#a7 ,affiliat$ ph>macy ,! t]m
 affiliat$ ph>macy means1 ) respect to a
 ,m$ic>e ,advantage plan (f]$ by a      
,m$ic>e ,advantage organization1 a      
ph>macy ) respect to :i* su*            
organization 7or any p]son ) an own]%ip 
or control int]e/ 7z def9$ 9 section    
#aabd7;a77#c77 9 su* organization7 is a 
p]son ) an own]%ip or control int]e/ 7z 
s def9$74  7#b7 ,applicable ye> ,! t]m  
applicable ye> means1 ) respect to a    
report submitt$ "u subsection 7a71 !    
fir/ cal5d> ye> beg9n+ at lea/ #d ye>s  
prior to ! date ( ! submission ( su*    
report4  7#c7 ,cov]$ "p ,d drug ,! t]m  
cov]$ "p ,d drug has ! mean+ giv5 su*   
t]m 9 section #ahfj;,d-#b7;e74  7#d7    

,direct & indirect remun]ation ,! t]m   
direct & indirect remun]ation has !     
mean+ giv5 su* t]m 9 section #dbc4cjh ( 
title #db1 ,code ( ,f$]al ,regulations  
7or any successor regulation74  7#e7    
,qualify+ diagnosis ,! t]m qualify+     
diagnosis means1 ) respect to an        
enrollee ( a ,m$ic>e ,advantage plan1 a 
diagnosis t is tak5 into acc\nt 9       
calculat+ a risk score = su* enrollee "u
 ! risk adju/m5t me?odology e/abli%$ by 
! ,secret>y pursuant to section         
#ahec7;a77#c74  7#f7 ,risk score ,! t]m 
risk score means1 ) respect to an       
enrollee ( a ,m$ic>e ,advantage plan1 ! 
score calculat$ = su* individual us+ !  
me?odology describ$ 9 p>agraph 7#e74    
7#g7 ,physician-adm9i/]$ drug ,! t]m    
physician-adm9i/]$ drug means a drug    
furni%$ to an individual t1 _h su*      
individual be5 enroll$ "u "p ,b & n     
enroll$ "u "p ,c1 w\ld h be5 payable "u 
section #ahdb7o74  7#h7 ,specifi$ heal? 
c>e provid] ,! t]m specifi$ heal? c>e   
provid] means1 ) respect to a ,m$ic>e   

,advantage plan (f]$ by a ,m$ic>e       
,advantage organization1 a heal? c>e    
provid] ) respect to :i* su*            
organization 7or any p]son ) an own]%ip 
or control int]e/ 7z def9$ 9 section    
#aabd7;a77#c77 9 su* organization7 is a 
p]son ) an own]%ip or control int]e/ 7z 
s def9$74  7#i7 ,specifi$ ph>macy ,! t]m
 specifi$ ph>macy means1 ) respect to a 
prescription drug plan (f]$ by a        
prescription drug plan sponsor1 a       
ph>macy ) respect to :i*-- 7,a7 su*     
sponsor 7or any p]son ) an own]%ip or   
control int]e/ 7z def9$ 9 section       
#aabd7;a77#c77 9 su* sponsor7 is a p]son
 ) an own]%ip or control int]e/ 7z s    
def9$72 or  7,b7 a ph>macy b5efit manag]
 (f]+ s]vices "u su* plan 7or any p]son 
) an own]%ip or control int]e/ 7z s     
def9$7 9 su* sponsor7 is a p]son ) an   
own]%ip or control int]e/ 7z s def9$74  
7#aj7 ,specifi$ ph>macy b5efit manag] ,!
 t]m specifi$ ph>macy b5efit manag]     
means1 ) respect to a prescription drug 
plan (f]$ by a prescription drug plan   

sponsor1 a ph>macy b5efit manag] )      
respect to :i* su* sponsor 7or any p]son
 ) an own]%ip or control int]e/ 7z def9$
 9 section #aabd7;a77#c77 9 su* sponsor7
 is a p]son ) an own]%ip or control     
int]e/ 7z s def9$74  4  #aji4 ,advisory 
,committee  7a7 ,9 g5]al ,n lat] ?an    
,janu>y #a1 #bjbe1 ! ,secret>y ( ,labor1
 ! ,secret>y ( ,heal? & ,human ,s]vices1
 & ! ,secret>y ( ! ,treasury %all jo9tly
 conv5e an advisory committee 79 ?is    
section ref]r$ to z ! committee7 consi/+
 ( #i memb]s to advise ! ,secret>ies on 
h[ to improve ! usefulness1             
accessibility1 & usability ( in=mation  
made available 9 accordance ! am5dm5ts  
made by sections #aje & #ajf1 & by      
section #bjd ( division ,,bb ( !        
,consolidat$ ,appropriation ,act1 #bjba 
7,public ,law #aaf-bfj71 /reaml9e !     
report+ ( su* in=mation1 & ensure t--   
7#a7 su* in=mation is accurate1         
accessible1 & is deliv]$ 9 a =m & mann] 
consi/5t ) ! requirem5ts ( su* section2 
7#b7 ! =m & mann] 9 :i* su* in=mation is

 deliv]$ is r\t9ely updat$ 9 accordance 
) widely-us$ practices 9 ord] to ensure 
accessibility2 &  7#c7 su* in=mation is 
available = audit 7includ+ by mak+      
recomm5dations relat+ to h[ ,f$]al &    
,/ate actors may conduct su* audits74   
7b7 ,memb]%ip ,! ,secret>ies %all jo9tly
 appo9t memb]s repres5t+ end-us]s ( !   
in=mation describ$ 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    
%all t]m9ate on ,janu>y #a1 #bjbh4  7d7 
,nonapplicaiton ( ,,faca ,! ,f$]al      
,advisory ,committee ,act 7#e ,u4,s4,c4 
,app47 %all n apply to ! committee4     
#aaj4 ,report on impact ( ,m$ic>e       
regulations on provid] & pay]           
consolidation  7a7 ,annual report on !  
impact ( c]ta9 ,m$ic>e regulations on   
provid] & pay] consolidation2 public    
comm5t on provid] & pay] consolidation =
 c]ta9 propos$ rules  7#a7 ,annual      
report ,n lat] ?an ,decemb] #cj1 #bjbf1 

& annually !reaft]1 ! ,secret>y ( ,heal?
 & ,human ,s]vices 79 ?is section ref]r$
 to z ! ,secret>y7 %all submit to       
,congress a report on ! impact 9 !      
aggregate on provid] & pay]             
consolidation ) respect to regulations =
 p>ts ,a1 ,b1 ,c1 & ,d ( title ,,xviii (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acie et seq47 implem5t$ 9 ! cal5d> ye>
 imm$iately prior to su* report4 ,su*   
report %all include regulations t--     
7,a7 implem5t a *ange to an applicable  
paym5t sy/em1 a rate s*$ule1 or ano!r   
paym5t sy/em "u "p ,a1 ,b1 ,c1 or ,d (  
su* title2 or  7,b7 result 9 a          
significant rule effect+ provid] or pay]
 consolidation4  7#b7 ,public comm5t on 
impact to provid] & pay] consolidation  
,beg9n+ = #bjbe1 z "p ( any notice &    
comm5t rulemak+ process t w result 9 a  
significant rule effect+ provid] or pay]
 consolidation ) respect to a propos$   
rule = p>ts ,a1 ,b1 ,c1 & ,d ( title    
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie;j et seq471 ! ,secret>y 

%all seek public comm5t on ! project$   
impact ( su* propos$ rule on provid] &  
pay] consolidation 9 ! aggregate4  7#c7 
,def9itions ,9 ?is section3  7,a7       
,provid] & pay] consolidation ,! t]m    
provid] & pay] consolidation includes ! 
v]tical or horizontal integration among 
provid]s ( s]vices 7z def9$ 9 subsection
 7u7 ( section #ahfa ( ! ,social        
,security ,act 7#db ,u4,s4,c4 #aciex771 
suppli]s 7z def9$ 9 subsection 7d7 ( su*
 section71 acc\ntable c>e organizations 
"u section #ahii ( ! ,social ,security  
,act 7#db ,u4,s4,c4 #acie;jjj71 ,m$ic>e 
,advantage organizations1 ,,pdp         
sponsors1 ph>macy b5efit manag]s1       
ph>macies1 & integrat$ deliv]y sy/ems4  
7,b7 ,applicable paym5t sy/em ,! t]m    
applicable paym5t sy/em includes--  7i7 
) respect to outpati5t hospital s]vices1
 ! prospective paym5t sy/em = cov]$     
,,opd s]vices e/abli%$ "u section       
#ahcc7t7 ( su* ,act 7#db ,u4,s4,c4      
#acie7l772 &  7ii7 ) respect to         
physicians' s]vices1 ! physician fee    

s*$ules e/abli%$ "u section #ahdh ( su* 
,act 7#db ,u4,s4,c4 #aciew-#d74  7b7    
,consid]ation ( effects on provid] &    
pay] consolidation ) respect to ,,cmi   
models  7#a7 ,9 g5]al ,section          
#aaae;,a7b77#d77;,a7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#acae;a7b77#d77;,a77 is am5d$-- 7,a7 9  
clause 7i71 by /rik+ at ! end &2  7,b7 9
 clause 7ii71 by /rik+ ! p]iod at ! end 
& ins]t+ 2 &2 &  7,c7 by add+ at ! end !
 foll[+ new clause3  7iii7 ! ext5t to   
:i*1 & h[1 ! model has effect$ & c\ld   
effect provid] & pay] consolidation1 :i*
 includes ! v]tical or horizontal       
integration among provid]s ( s]vices 7z 
def9$ 9 subsection 7u7 ( section #ahfa71
 suppli]s 7z def9$ 9 subsection 7d7 (   
su* section71 & acc\ntable c>e          
organizations "u section #ahii4  4  7#b7
 ,effective date ,! am5dm5ts made by    
p>agraph 7#a7 %all apply ) respect to   
models te/$ on or aft] ,janu>y #a1      
#bjbe4  #aaa4 ,implem5tation fund+  7a7 
,9 g5]al ,= ! purposes describ$ 9       

subsection 7b71 !re are appropriat$1 9  
addition to am\nts o!rwise available1   
out ( am\nts 9 ! ,treasury n o!rwise    
appropriat$1 to ! ,secret>y ( ,heal? &  
,human ,s]vices & ! ,secret>y ( !       
,treasury1 #fe1jjj1jjj = fiscal ye>     
#bjbd1 to rema9 available ?r\gh fiscal  
ye> #bjbi4  7b7 ,p]mitt$ purposes ,!    
purposes describ$ 9 ?is subsection are !
 foll[+ purposes1 ins(> z su* purposes  
are to c>ry out ! provisions (1 includ+ 
! am5dm5ts made by1 ?is title3  7#a7    
,prep>+1 draft+1 & issu+ propos$ & f9al 
regulations or int]im regulations4  7#b7
 ,prep>+1 draft+1 & issu+ guidance &    
public in=mation4  7#c7 ,prep>+1 draft+1
 & publi%+ reports4  7#d7 ,en=cem5t (   
su* provisions4  7#e7 ,report+1         
collection1 & analysis ( data4  7#f7    
,o!r adm9i/rative duties necess>y =     
implem5tation ( su* provisions4  7c7    
,transp>5cy ( implem5tation funds ,ea*  
,secret>y describ$ 9 subsection 7a7 %all
 annually submit1 no lat] ?an ,septemb] 
#a/ ( ea* ye>1 to ! ,committees on      

,en]gy & ,comm]ce1 on ,ways & ,means1 on
 ,education & ,work=ce1 & on            
,appropriations ( ! ,h\se (             
,repres5tatives & on ! ,committees on   
,heal?1 ,education1 ,labor1 & ,p5sions &
 on ,appropriations ( ! ,s5ate a report 
on funds exp5d$ pursuant to funds       
appropriat$ "u ?is section4  ,,ii ,r$uc+
 ,heal? ,c>e ,co/s = ,pati5ts  #bja4    
,increas+ transp>5cy 9 g5]ic drug       
applications  7a7 ,9 g5]al ,section     
#eje7;j77#c7 ( ! ,f$]al ,food1 ,drug1 & 
,cosmetic ,act 7#ba ,u4,s4,c4           
#cee7;j77#c77 is am5d$ by add+ at ! end 
! foll[+3  7,h7  7i7 ,^u reque/ 79      
controll$ correspond5ce or an analog\s  
process7 by a p]son t has submitt$ or   
int5ds to submit an abbreviat$          
application "u ?is subsection = a drug t
 is requir$ by regulation to conta9 "o  
or m ( ! same inactive +r$i5ts 9 ! same 
conc5trations z ! li/$ drug ref]r$ to1  
or = :i* ! ,secret>y det]m9es !re is a  
sci5tific ju/ification = an approa* t is
 9 vitro 9 :ole or 9 "p to be us$ to    

demon/rate bioequival5ce = a drug if su*
 a drug conta9s "o or m ( ! same        
inactive +r$i5ts 9 ! same conc5trations 
z ! li/$ drug1 ! ,secret>y %all in=m !  
p]son :e!r su* drug is qualitatively &  
quantitatively ! same z ! li/$ drug4 ,! 
,secret>y may also provide su* in=mation
 to su* a p]son on ! ,secret>y's own    
initiative dur+ ! review ( an abbreviat$
 application "u ?is subsection = su*    
drug4  7ii7 ,not)/&+ section #cja7;j71  
if ! ,secret>y det]m9es t su* drug is n 
qualitatively or quantitatively ! same z
 ! li/$ drug1 ! ,secret>y %all id5tify &
 disclose to ! p]son--  7,i7 ! +r$i5t or
 +r$i5ts t cause su* drug n to be       
qualitatively or quantitatively ! same z
 ! li/$ drug2 &  7,,ii7 = any +r$i5t =  
:i* !re is an id5tifi$ quantitative     
deviation1 ! am\nt ( su* deviation4     
7iii7 ,if ! ,secret>y det]m9es t su*    
drug is qualitatively & quantitatively !
 same z ! li/$ drug1 ! ,secret>y %all n 
*ange or resc9d su* det]m9ation aft] !  
submission ( an abbreviat$ application =

 su* drug "u ?is subsection unless--    
7,i7 ! =mulation ( ! li/$ drug has be5  
*ang$ & ! ,secret>y has det]m9$ t !     
prior li/$ drug =mulation 0 )drawn =    
reasons ( safety or effectiv5ess2 or    
7,,ii7 ! ,secret>y makes a writt5       
det]m9ation t ! prior det]m9ation mu/ be
 *ang$ because an error has be5         
id5tifi$4  7iv7 ,if ! ,secret>y makes a 
writt5 det]m9ation describ$ 9 clause    
7iii77,,ii71 ! ,secret>y %all provide   
notice & a copy ( ! writt5 det]m9ation  
to ! p]son mak+ ! reque/ "u clause 7i74 
7v7 ,! disclosures requir$ by ?is       
subp>agraph are disclosures au?oriz$ by 
law1 includ+ = purposes ( section #aije 
( title #ah1 ,unit$ ,/ates ,code4  4    
7b7 ,guidance  7#a7 ,9 g5]al ,n lat] ?an
 "o ye> aft] ! date ( enactm5t ( ?is    
,act1 ! ,secret>y ( ,heal? & ,human     
,s]vices %all issue draft guidance1 or  
update guidance1 describ+ h[ ! ,secret>y
 w det]m9e :e!r a drug is qualitatively 
& quantitatively ! same z ! li/$ drug 7z
 su* t]ms are us$ 9 section             

#eje7;j77#c77;,h7 ( ! ,f$]al ,food1     
,drug1 & ,cosmetic ,act1 z add$ by      
subsection 7a771 includ+ ) respect to   
assess+ p,h adju/]s4  7#b7 ,process ,9  
issu+ guidance "u ?is subsection1 !     
,secret>y ( ,heal? & ,human ,s]vices    
%all-- 7,a7 publi% draft guidance2  7,b7
 provide a p]iod ( at lea/ #fj days =   
comm5t on ! draft guidance2 &  7,c7 aft]
 consid]+ any comm5ts receiv$ & n lat]  
?an "o ye> aft] ! close ( ! comm5t p]iod
 on ! draft guidance1 publi% f9al       
guidance4  7c7 ,applicability ,section  
#eje7;j77#c77;,h7 ( ! ,f$]al ,food1     
,drug1 & ,cosmetic ,act1 z add$ by      
subsection 7a71 applies beg9n+ on ! date
 ( enactm5t ( ?is ,act1 irrespective ( !
 date on :i* ! guidance requir$ by      
subsection 7b7 is f9aliz$4  #bjb4       
,improv+ transp>5cy & prev5t+ ! use (   
abusive spread pric+ & relat$ practices 
9 ,m$icaid  7a7 ,spread pric+  7#a7 ,9  
g5]al ,section #aibg7;e7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acifr-#h7;e77 is am5d$ by add+ at ! end

 ! foll[+3  7#f7 ,ph>macy price         
reimbursem5t requir$  7,a7 ,9 g5]al ,a  
contract betwe5 ! ,/ate & a ph>macy     
b5efit manag] 79 ?is p>agraph ref]r$ to 
z a ,,pbm71 or a contract betwe5 ! ,/ate
 & a designat$ entity 7z def9$ 9        
subp>agraph 7,c77 t includes provisions 
mak+ ! designat$ entity responsible = ! 
adm9i/ration ( m$ical assi/ance consi/+ 
( cov]$ outpati5t drugs = individuals   
enroll$ ) ! designat$ entity1 %all      
require t paym5t = su* drugs & relat$   
adm9i/rative s]vices 7z applicable71    
includ+ paym5ts made by a ,,pbm on      
behalf ( ! ,/ate or designat$ entity1 is
 bas$ on a ph>macy price reimbursem5t   
model "u :i*-- 7i7 any paym5t made by ! 
designat$ entity or ! ,,pbm 7z          
applicable7 = su* a drug--  7,i7 is     
limit$ to-- 7aa7 +r$i5t co/2 &  7bb7 a  
pr(essional disp5s+ fee t is n less ?an 
! pr(essional disp5s+ fee t ! ,/ate plan
 or waiv] w\ld pay if ! plan or waiv] 0 
mak+ ! paym5t directly2  7,,ii7 is pass$
 ?r\gh 9 its entirety by ! designat$    

entity or ,,pbm to ! ph>macy or provid] 
t disp5ses ! drug & is n retroactively  
d5i$ or r$uc$ except z p]mitt$ or       
requir$ "u ,f$]al or ,/ate law or       
regulation2 &  7,,iii7 is made 9 a mann]
 t is consi/5t ) sections #ddg4ejb1     
#ddg4eab1 #ddg4ead1 & #ddg4eah ( title  
#db1 ,code ( ,f$]al ,regulations 7or any
 successor regulation7 z if su*         
requirem5ts appli$ directly to !        
designat$ entity or ! ,,pbm1 except t   
any paym5t by ! designat$ entity or !   
,,pbm = ! +r$i5t co/ ( su* a drug       
pur*as$ by a cov]$ entity 7z def9$ 9    
subsection 7a77#e77;,b77 may exce$ !    
actual acquisition co/ 7z def9$ 9       
section #ddg4ejb ( title #db1 ,code (   
,f$]al ,regulations 7or any successor   
regulation77 = su* drug if-- 7aa7 su*   
drug 0 subject to an agreem5t "u section
 #cdj;,b ( ! ,public ,heal? ,s]vice     
,act2  7bb7 su* paym5t = su* co/ ( su*  
drug does n exce$ ! maximum paym5t t    
w\ld h be5 made by ! designat$ entity or
 ! ,,pbm = ! +r$i5t co/ ( su* drug _h   

su* drug n be5 pur*as$ by su* a cov]$   
entity2 &  7cc7 su* cov]$ entity reports
 to ! ,secret>y1 on an annual basis 79 a
 =m & mann] specifi$ by ! ,secret>y7 & )
 respect to paym5ts = su* co/s ( su*    
drugs s pur*as$ by su* cov]$ entity t   
are 9 excess ( ! actual acquisition co/s
 = su* drugs1 ! aggregate am\nt ( su*   
excess2  7ii7 paym5t to ! designat$     
entity or ! ,,pbm 7z applicable7 =      
adm9i/rative s]vices p]=m$ by !         
designat$ entity or ,,pbm is limit$ to  
an adm9i/rative fee t reflects ! fair   
m>ket value ( provid+ su* s]vices2      
7iii7 ! designat$ entity or ! ,,pbm 7z  
applicable7 makes available to ! ,/ate1 
& ! ,secret>y ^u reque/1 all co/s &     
paym5ts relat$ to cov]$ outpati5t drugs 
& accompany+ adm9i/rative s]vices       
incurr$1 receiv$1 or made by ! designat$
 entity or ! ,,pbm1 includ+ +r$i5t co/s1
 pr(essional disp5s+ fees1 adm9i/rative 
fees1 po/-sale & po/-invoice fees1      
disc\nts1 or relat$ adju/m5ts su* z     
direct & indirect remun]ation fees1 &   

any & all o!r remun]ation2 &  7iv7 any  
=m ( spread pric+ :]eby any am\nt *>g$  
or claim$ by ! designat$ entity or !    
,,pbm 7z applicable7 is 9 excess ( !    
am\nt paid to ! ph>macies by ! designat$
 entity or ! ,,pbm1 includ+ any po/-sale
 or po/-invoice fees1 disc\nts1 or      
relat$ adju/m5ts su* z direct & indirect
 remun]ation fees or assessm5ts 7aft]   
all[+ = a fair m>ket adm9i/rative fee z 
describ$ 9 clause 7ii771 is n all[able =
 purposes ( claim+ ,f$]al mat*+ paym5ts 
"u ?is title4  7,b7 ,mak+ c]ta9         
in=mation available ,! ,secret>y %all   
publi%1 n less frequ5tly ?an on an      
annual basis1 in=mation receiv$ by !    
,secret>y pursuant to subp>agraph       
7,a77i77,,iii77cc74 ,su* in=mation %all 
be s publi%$ 9 an electronic & se>*able 
=mat1 su* z ?r\gh ! #cdj;,b ,(fice (    
,ph>macy ,affairs ,in=mation ,sy/em 7or 
a successor sy/em74  7,c7 ,def9itions ,9
 ?is p>agraph3 7i7 ,designat$ entity ,! 
t]m designat$ entity means a manag$ c>e 
entity or o!r specifi$ entity4  7ii7    

,manag$ c>e entity2 o!r specifi$ entity 
,! t]ms manag$ c>e entity & o!r specifi$
 entity h ! mean+ giv5 su* t]ms 9       
section #aijc7m77#i77;,d74  4  7#b7     
,con=m+ am5dm5ts ,section #aijc7m7 ( su*
 ,act 7#db ,u4,s4,c4 #acif;b7m77 is     
am5d$--  7,a7 9 p>agraph                
7#b77;,a77xiii7-- 7i7 by /rik+ & 7,,iii7
 & ins]t+ 7,,iii72  7ii7 by ins]t+ be=e 
! p]iod at ! end ! foll[+3 1 & 7,,iv7 ) 
respect to cov]$ outpati5t drugs &      
relat$ adm9i/rative s]vices 7z          
applicable7 provid$ by ! entity 7or by a
 ph>macy b5efit manag] on behalf ( !    
entity "u a contract or o!r arrangem5t )
 ! entity71 t paym5t = su* drugs &      
relat$ adm9i/rative s]vices is bas$ on a
 ph>macy price reimbursem5t model       
describ$ 9 section #aibg7;e77#f77;,a72 &
  7iii7 by mov+ ! m>g9 #b ems to ! left2
 &  7,b7 by add+ at ! end ! foll[+ new  
p>agraph3  7#aj7 ,no paym5t %all be made
 "u ?is title to a ,/ate ) respect to   
exp5ditures incurr$ by x = paym5t =     
s]vices provid$ by an o!r specifi$      

entity 7z def9$ 9 p>agraph 7#i77;,d77   
unless ! contract betwe5 ! ,/ate & !    
entity = ! provision ( su* s]vices      
provides1 ) respect to cov]$ outpati5t  
drugs & relat$ adm9i/rative s]vices 7z  
applicable7 provid$ by ! entity 7or by a
 ph>macy b5efit manag] on behalf ( !    
entity "u a contract or o!r arrangem5t )
 ! entity71 t paym5t = su* drugs &      
relat$ adm9i/rative s]vices is bas$ on a
 ph>macy price reimbursem5t model       
describ$ 9 section #aibg7;e77#f77;,a74  
4  7#c7 ,effective date ,! am5dm5ts made
 by ?is subsection apply to contracts   
betwe5 ,/ates & ph>macy b5efit manag]s &
 designat$ entities 7z def9$ 9 section  
#aibg7;e77#f7 ( ! ,social ,security     
,act1 z add$ by p>agraph 7#a77 t h an   
effective date beg9n+ on or aft] ! date 
t is #ah mon?s aft] ! date ( enactm5t ( 
?is ,act4  7b7 ,ensur+ accurate paym5ts 
to ph>macies "u ,m$icaid  7#a7 ,9 g5]al 
,section #aibg7;f7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acifr-#h7;f77 is  
am5d$--  7,a7 by /rik+ & aft] !         

semicolon at ! end ( p>agraph           
7#a77;,a77i7 & all t prec$es x ?r\gh    
7#a7 & ins]t+ ! foll[+3  7#a7 ,det]m9+  
ph>macy actual acquisition co/s ,!      
,secret>y %all conduct a survey ( retail
 community ph>macy drug prices to       
det]m9e ! national av]age drug          
acquisition co/ z foll[s3  7,a7 ,use (  
v5dor ,! ,secret>y may contract s]vices 
=-- 7i7 ) respect to retail community   
ph>macies1 ! det]m9ation ( retail survey
 prices ( ! national av]age drug        
acquisition co/ = cov]$ outpati5t drugs 
bas$ on a mon?ly survey ( su* ph>macies2
 &  2  7,b7 by add+ at ! end ( p>agraph 
7#a7 ! foll[+3  7,f7 ,survey report+ ,a 
,/ate %all require t any retail         
community ph>macy 9 ! ,/ate t receives  
any paym5t1 reimbursem5t1 adm9i/rative  
fee1 disc\nt1 or rebate relat$ to !     
disp5s+ ( cov]$ outpati5t drugs to      
individuals receiv+ b5efits "u ?is      
title1 reg>dless ( :e!r su* paym5t1     
reimbursem5t1 adm9i/rative fee1 disc\nt1
 or rebate is receiv$ f ! ,/ate or a    

designat$ entity 7z def9$ 9 subsection  
7e77#f77;,c77 directly or f a ph>macy   
b5efit manag] t has a contract ) ! ,/ate
 or a designat$ entity1 %all respond to 
surveys ( retail prices conduct$ "u ?is 
subsection4  7,g7 ,survey in=mation     
,in=mation on national drug acquisition 
prices obta9$ "u ?is p>agraph %all be   
made publicly available 9 a timely mann]
 foll[+ ! collection ( su* in=mation &  
%all include at lea/ ! foll[+3 7i7 ,!   
mon?ly response rate to ! survey includ+
 a li/ ( ph>macies n 9 compliance )     
subp>agraph 7,f74  7ii7 ,! sampl+ frame 
& numb] ( ph>macies sampl$ mon?ly4      
7iii7 ,in=mation on price concessions to
 ! ph>macy1 includ+ disc\nts1 rebates1 &
 o!r price concessions1 to ! ext5t t su*
 in=mation may be publicly releas$ & is 
available dur+ ! survey p]iod4  7,h7    
,report on specialty ph>macies ,n lat]  
?an #a ye> aft] ! date t ?is subp>agraph
 takes effect1 ! ,secret>y %all submit  
to ,congress a report exam9+ specialty  
drug cov]age & reimbursem5t "u ?is      

title1 includ+-- 7i7 a description ( h[ 
,/ate ,m$icaid programs def9e specialty 
drugs & specialty ph>macies2  7ii7 !    
am\nt ,/ate ,m$icaid programs pay =     
specialty drugs2  7iii7 h[ ,/ates &     
designat$ entities 7z def9$ 9 subsection
 7e77#f77;,c77 det]m9e paym5t =         
specialty drugs2  7iv7 ! sett+s 9 :i*   
specialty drugs are disp5s$ to          
individuals receiv+ b5efits "u ?is title
 7su* z retail community ph>macies or   
specialty ph>macies72  7v7 ! ext5t to   
:i* specialty drugs 7z def9$ by !       
respective ,/ates7 are captur$ 9 !      
national av]age drug acquisition co/    
survey 7or ?r\gh ano!r process72  7vi7  
examples ( specialty drug disp5s+ fees  
to support ! s]vices associat$ ) disp5s+
 su* specialty drugs2 &  7vii7          
recomm5dations z to :e!r specialty      
ph>macies %\ld be includ$ 9 ! survey (  
retail prices to ensure national av]age 
drug acquisition co/s capture drugs sold
 at specialty ph>macies1 & h[ su*       
specialty ph>macies %\ld be def9$4  7,i7

 ,en=cem5t ,at ! discretion ( !         
,secret>y1 ! ,secret>y 7act+ ?r\gh !    
,inspector ,g5]al & 9 collaboration ) ! 
,adm9i/rator ( ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices7 may en=ce            
non-compliance ) ?is p>agraph by a      
ph>macy ?r\gh ! e/abli%m5t ( p5alties   
until compliance ) ?is p>agraph has be5 
complet$4  2 &  7,c7 9 p>agraph 7#b7--  
7i7 9 subp>agraph 7,a71 by ins]t+       
7includ+ paym5t rates "u manag$ c>e     
organization z def9$ 9 section          
#aicb7;a77#a77;,b77i7 & ,p,i,h,ps &     
,p,a,h,ps z def9$ 9 section             
#aijc7m77#i77;,d77iii77,i7 & 7,,ii71    
respectively7 aft] "u ?is title2 &  7ii7
 9 subp>agraph 7,b71 by ins]t+ 1 & !    
basis = su* disp5s+ fees be=e !         
semicolon at ! end4  7#b7 ,effective    
date ,! am5dm5ts made by ?is subsection 
%all take effect on ! fir/ day ( ! fir/ 
qu>t] t beg9s on or aft] ! date t is #ah
 mon?s aft] ! date ( enactm5t ( ?is     
,act4  #bjc4 ,p>ity 9 ,m$ic>e paym5ts = 
hospital outpati5t dep>tm5t s]vices     

furni%$ (f-campus  7a7 ,9 g5]al ,section
 #ahcc7t77#af7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciel7t77#af77 is  
am5d$ by add+ at ! end ! foll[+ new     
subp>agraph3  7,h7 ,p>ity 9 fee s*$ule  
am\nt = c]ta9 s]vices furni%$ by an     
(f-campus outpati5t dep>tm5t ( a provid]
  7i7 ,9 g5]al ,subject to clause 7iii71
 9 ! case ( specifi$ ,,opd s]vices 7z   
def9$ 9 clause 7v77 t are furni%$ dur+  
#bjbe or a subsequ5t ye> by an (f-campus
 outpati5t dep>tm5t ( a provid] 7z def9$
 9 clause 7iv77 7or1 9 ! case ( an      
(f-campus outpati5t dep>tm5t ( a provid]
 t is a hospital describ$ 9 section     
#ahhf7;d77#a77;,b77v71 or is locat$ 9 a 
rural area or a heal? pr(essional       
%ortage area1 su* s]vices t are furni%$ 
dur+ #bjbf or a subsequ5t ye>71 !re %all
 be sub/itut$ = ! am\nt o!rwise det]m9$ 
"u ?is subsection = su* s]vice & ye> an 
am\nt equal to ! paym5t am\nt t w\ld h  
be5 payable "u ! applicable paym5t sy/em
 "u ?is "p 7o!r ?an "u ?is subsection7  
_h su* s]vices be5 furni%$ by su* a     

dep>tm5t subject to su* paym5t sy/em    
pursuant to p>agraph 7#ba77;,c74  7ii7  
,n budget neutral implem5tation ,9 mak+ 
any budget neutrality adju/m5ts "u ?is  
subsection = #bjbe or a subsequ5t ye>1 !
 ,secret>y %all n take into acc\nt !    
r$uc$ exp5ditures t result f !          
application ( ?is subp>agraph4  7iii7   
,transition ,! ,secret>y %all provide = 
a #d-ye> phase-9 ( ! application (      
clause 7i71 ) clause 7i7 be+ fully      
applicable = specifi$ ,,opd s]vices     
beg9n+ ) #bjbh 7or 9 ! case ( an        
(f-campus outpati5t dep>tm5t ( a provid]
 t is a hospital describ$ 9 section     
#ahhf7;d77#a77;,b77v71 or is locat$ 9 a 
rural area or a heal? pr(essional       
%ortage area1 beg9n+ ) #bjbi74  7iv7    
,(f-campus dep>tm5t ( a provid] ,=      
purposes ( ?is subp>agraph1 ! t]m       
(f-campus outpati5t dep>tm5t ( a provid]
 means a dep>tm5t ( a provid] 7z def9$ 9
 section #dac4fe7;a77#b7 ( title #db1   
,code ( ,f$]al ,regulations7 t is n     
locat$--  7,i7 on ! campus 7z su* t]m is

 def9$ 9 su* section7 ( su* provid]2 or 
7,,ii7 )9 ! di/ance 7describ$ 9 su*     
def9ition ( campus7 f a remote location 
( a hospital facility 7z def9$ 9 su*    
section74  7v7 ,o!r def9itions ,=       
purposes ( ?is subp>agraph3 7,i7        
,designat$ ambulatory paym5t            
classification gr\p ,! t]m designat$    
ambulatory paym5t classification gr\p   
means an ambulatory paym5t              
classification gr\p = drug adm9i/ration 
s]vices4  7,,ii7 ,heal? pr(essional     
%ortage area ,! t]m heal? pr(essional   
%ortage area has ! mean+ giv5 su* t]m 9 
section #ccb7;a77#a77;,a7 ( ! ,public   
,heal? ,s]vice ,act4  7,,iii7 ,rural    
area ,! t]m rural area has ! mean+ giv5 
su* t]m 9 section #ahhf7;d77#b77;,d74   
7,,iv7 ,specifi$ ,,opd s]vices ,! t]m   
specifi$ ,,opd s]vices means cov]$ ,,opd
 s]vices assign$ to a designat$         
ambulatory paym5t classification gr\p4  
4  7b7 ,implem5tation ,section          
#ahcc7t77#ab7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciel7t77#ab77 is      

am5d$--  7#a7 9 subp>agraph 7,d71 by    
/rik+ & at ! end2  7#b7 9 subp>agraph   
7,e71 by /rik+ ! p]iod at ! end & ins]t+
 2 &2 &  7#c7 by add+ at ! end ! foll[+ 
new subp>agraph3  7,f7 ! det]m9ation (  
any paym5t am\nt "u p>agraph 7#af77;,h71
 includ+ ! transition "u clause 7iii7 ( 
su* p>agraph4  4  #bjd4 ,requir+ a      
sep>ate id5tification numb] & an        
atte/ation = ea* (f-campus outpati5t    
dep>tm5t ( a provid]  7a7 ,9 g5]al      
,section #ahcc7t7 ( ! ,social ,security 
,act 7#db ,u4,s4,c4 #aciel7t77 is am5d$ 
by add+ at ! end ! foll[+ new p>agraph3 
7#bc7 ,use ( unique heal? id5tifi]s2    
atte/ation  7,a7 ,9 g5]al ,no paym5t may
 be made "u ?is subsection 7or "u an    
applicable paym5t sy/em pursuant to     
p>agraph 7#ba77 = items & s]vices       
furni%$ on or aft] ,janu>y #a1 #bjbf1 by
 an (f-campus outpati5t dep>tm5t ( a    
provid] 7z def9$ 9 subp>agraph 7,c77    
unless--  7i7 su* dep>tm5t has obta9$1 &
 su* items & s]vices are bill$ "u1 a    
/&>d unique heal? id5tifi] = heal? c>e  

provid]s 7z describ$ 9 section          
#aagc7;b77 t is sep>ate f su* id5tifi] =
 su* provid]2 &  7ii7 su* provid] has   
submitt$ to ! ,secret>y1 dur+ ! #b-ye>  
p]iod end+ on ! date su* items & s]vices
 are s furni%$1 an atte/ation t su*     
dep>tm5t is compliant ) ! requirem5ts   
describ$ 9 section #dac4fe ( title #db1 
,code ( ,f$]al ,regulations 7or a       
successor regulation74  7,b7 ,process = 
submission & review ,n lat] ?an #a ye>  
aft] ! date ( enactm5t ( ?is p>agraph1 !
 ,secret>y %all1 ?r\gh notice & comm5t  
rulemak+1 e/abli% a process = ea*       
provid] ) an (f-campus outpati5t        
dep>tm5t ( a provid] to submit an       
atte/ation pursuant to subp>agraph      
7,a77ii71 & = ! ,secret>y to review ea* 
su* atte/ation & det]m9e1 ?r\gh site    
visits1 remote audits1 or o!r means 7z  
det]m9$ appropriate by ! ,secret>y71    
:e!r su* dep>tm5t is compliant ) !      
requirem5ts describ$ 9 su* subp>agraph4 
7,c7 ,(f-campus outpati5t dep>tm5t ( a  
provid] def9$ ,= purposes ( ?is         

p>agraph1 ! t]m (f-campus outpati5t     
dep>tm5t ( a provid] means a dep>tm5t ( 
a provid] 7z def9$ 9 section #dac4fe (  
title #db1 ,code ( ,f$]al ,regulations1 
or any successor regulation7 t is n     
locat$--  7i7 on ! campus 7z def9$ 9 su*
 section7 ( su* provid]2 or  7ii7 )9 !  
di/ance 7describ$ 9 su* def9ition (     
campus7 f a remote location ( a hospital
 facility 7z def9$ 9 su* section74  4   
7b7 ,,hhs ,,oig analysis ,n lat] ?an    
,janu>y #a1 #bjcj1 ! ,inspector ,g5]al (
 ! ,dep>tm5t ( ,heal? & ,human ,s]vices 
%all submit to ,congress-- 7#a7 an      
analysis ( ! process e/abli%$ by !      
,secret>y ( ,heal? & ,human ,s]vices to 
conduct ! reviews & det]m9ations        
describ$ 9 section #ahcc7t77#bc77;,b7 ( 
! ,social ,security ,act1 z add$ by     
subsection 7a7 ( ?is section2 &  7#b7   
recomm5dations bas$ on su* analysis1 z !
 ,inspector ,g5]al det]m9es appropriate4
  ,,iii ,support+ ,pati5ts1 ,heal? ,c>e 
,work]s1 ,community ,heal? ,c5t]s1 &    
,hospitals  #cja4 ,ext5sion = community 

heal? c5t]s1 ! national heal? s]vice    
corps1 & tea*+ heal? c5t]s t op]ate     
,,gme programs  7a7 ,tea*+ heal? c5t]s t
 op]ate graduate m$ical education       
programs  7#a7 ,addition to capp$ am\nts
 = fiscal ye>s #bjbd & #bjbe ,p>agraph  
7#b7 ( section #cdj;,h7b7 ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bef;h7b77 is am5d$ by add+ at ! end !  
foll[+3  7,c7 ,addition ,not)/&+ any    
provision ( ?is section1 = ea* ( fiscal 
ye>s #bjbd & #bjbe1 ! ,secret>y may use 
any am\nts made available 9 any fiscal  
ye> to c>ry out ?is section 7includ+    
am\nts rec\p$ "u subsection 7f77 to make
 paym5ts describ$ 9 p>agraphs 7#a77;,a7 
& 7#a77;,b71 9 addition to ! total am\nt
 ( funds appropriat$ "u subsection 7g74 
4  7#b7 ,reconciliation ,section        
#cdj;,h7f7 ( ! ,public ,heal? ,s]vice   
,act 7#db ,u4,s4,c4 #bef;h7f77 is       
am5d$--  7,a7 by /rik+ ,! ,secret>y %all
 det]m9e & ins]t+ ! foll[+3  7#a7       
,det]m9ation ,! ,secret>y %all det]m9e  
2 &  7,b7 by add+ at ! end ! foll[+3    

7#b7 ,annual report to ,congress ,= ea* 
fiscal ye>1 ! ,secret>y %all submit to !
 ,committee on ,en]gy & ,comm]ce ( !    
,h\se ( ,repres5tatives & ! ,committee  
on ,heal?1 ,education1 ,labor1 &        
,p5sions ( ! ,s5ate a report specify+-- 
7,a7 ! total am\nt ( funds rec\p$ "u    
p>agraph 7#a72  7,b7 ! rationale = !    
funds be+ rec\p$2 &  7,c7 9 ! case ( !  
reports = ea* ( fiscal ye>s #bjbd &     
#bjbe1 ! total am\nt ( funds rec\p$ "u  
p>agraph 7#a7 t 7 us$ pursuant to       
subsection 7b77#b77;,c7 to adju/ total  
paym5t am\nts above ! total am\nts      
appropriat$ "u subsection 7g74  4  7#c7 
,fund+ ,section #cdj;,h7g7 ( ! ,public  
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bef;h7g77 is am5d$--  7,a7 by am5d+    
p>agraph 7#a7 to read z foll[s3  7#a7 ,9
 g5]al ,to c>ry out ?is section1 !re are
 appropriat$ su* sums z may be necess>y1
 n to exce$--  7,a7 #bcj1jjj1jjj1 = !   
p]iod ( fiscal ye>s #bjaa ?r\gh #bjae2  
7,b7 #fj1jjj1jjj = ea* ( fiscal ye>s    
#bjaf & #bjag2  7,c7 #abf1ejj1jjj = ea* 

( fiscal ye>s #bjah ?r\gh #bjbc2  7,d7  
#af1fce1faf = ! p]iod beg9n+ on ,octob] 
#a1 #bjbc1 & end+ on ,novemb] #ag1      
#bjbc2  7,e7 #ba1hcd1bdg = ! p]iod      
beg9n+ on ,novemb] #ah1 #bjbc1 & end+ on
 ,janu>y #ai1 #bjbd2  7,f7 #acf1ecj1acg 
= ! p]iod beg9n+ on ,janu>y #bj1 #bjbd1 
& end+ on ,septemb] #cj1 #bjbd2  7,g7   
#age1jjj1jjj = fiscal ye> #bjbe2  7,h7  
#bbe1jjj1jjj = ea* ( fiscal ye>s #bjbf &
 #bjbg2 &  7,i7 #cjj1jjj1jjj = ea* (    
fiscal ye>s #bjbh1 #bjbi1 & #bjcj4  2 & 
7,b7 by add+ at ! end ! foll[+3  7#c7   
,availability ,! am\nts made available  
"u p>agraph 7#a7 %all rema9 available   
until exp5d$4  4  7b7 ,ext5sion =       
community heal? c5t]s ,section          
#ajejc7;b77#a77;,f7 ( ! ,pati5t         
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #bed;b-#b7;b77#a77;,f77 is    
am5d$--  7#a7 by /rik+ & be=e           
#fij1daj1iei2 &  7#b7 by ins]t+ 1       
#c1ahc1efa1fdd = ! p]iod beg9n+ on      
,janu>y #bj1 #bjbd1 & end+ on ,septemb] 
#cj1 #bjbd1 #d1djj1jjj1jjj = fiscal ye> 

#bjbe1 & #a1aji1jjj1jjj = ! p]iod beg9n+
 ,octob] #a1 #bjbe1 & end+ ,decemb] #ca1
 #bjbe be=e ! semicolon at ! end4  7c7  
,ext5sion = ! ,national ,heal? ,s]vice  
,corps ,section #ajejc7;b77#b7 ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #bed;b-#b7;b77#b77  
is am5d$-- 7#a7 9 subp>agraph 7,h71 by  
/rik+ & at ! end2  7#b7 9 subp>agraph   
7,i71 by /rik+ ! p]iod at ! end & ins]t+
 2 &2 &  7#c7 by add+ at ! end ! foll[+3
  7,j7 #bee1gbf1jbh = ! p]iod beg9n+ on 
,janu>y #bj1 #bjbd1 & end+ on ,septemb] 
#cj1 #bjbd1 #cej1jjj1jjj = fiscal ye>   
#bjbe1 & #hh1bai1agh = ! p]iod beg9n+   
,octob] #a1 #bjbe1 & end+ ,decemb] #ca1 
#bjbe4  4  7d7 ,gov]nm5t ,acc\ntability 
,(fice report  7#a7 ,9 g5]al ,n lat] ?an
 "o ye> aft] ! date ( enactm5t ( ?is    
,act1 ! ,comptroll] ,g5]al ( ! ,unit$   
,/ates %all submit to ! ,committee on   
,en]gy & ,comm]ce ( ! ,h\se (           
,repres5tatives & ! ,committee on       
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate a report assess+ !            

effectiv5ess ( ! ,national ,heal?       
,s]vice ,corps at attract+ heal? c>e    
pr(essionals to ,h,p,s,as1 includ+ by-- 
7,a7 assess+ ! metrics us$ by ! ,heal?  
,res\rces & ,s]vices ,adm9i/ration 9    
evaluat+ ! program2  7,b7 comp>+ !      
ret5tion rates ( ,,nhsc p>ticipants 9 ! 
,h,p,s,as :]e !y complet$ _! p]iod (    
obligat$ s]vice to ! ret5tion rate (    
non-,,nhsc p>ticipants 9 ! correspond+  
,h,p,s,as2  7,c7 comp>+ ! ret5tion rates
 ( ,,nhsc p>ticipants 9 ! ,h,p,s,as :]e 
!y complet$ _! p]iod ( obligat$ s]vice  
to ! ret5tion rates ( ,,nhsc p>ticipants
 9 ,h,p,s,as o!r ?an ^? :]e !y complet$ 
_! p]iod ( obligat$ s]vice2  7,d7       
id5tify+ factors t influ5ce a ,,nhsc    
p>ticipant's decision to practice 9 a   
,,hpsa o!r ?an ! ,,hpsa :]e !y complet$ 
_! p]iod ( obligat$ s]vice2  7,e7       
id5tify+ factors o!r ?an p>ticipation 9 
! ,national ,heal? ,s]vice ,corps       
,s*ol>%ip & ,loan ,repaym5t ,programs t 
attract heal? c>e pr(essionals to a     
,,hpsa2  7,f7 assess+ ! impact !        

,national ,heal? ,s]vice ,corps has on  
wages = heal? c>e pr(essionals 9 a      
,,hpsa2 &  7,g7 comp>+ ! di/ribution (  
,,nhsc p>ticipants across ,h,p,s,as1    
includ+ a comp>ison ( rural v]sus       
non-rural ,h,p,s,as4  7#b7 ,def9ition ,9
 ?is section3  7,a7 ,! t]m ,,hpsa means 
a heal? pr(essional %ortage area        
designat$ "u section #ccb ( ! ,public   
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#bed;e74  7,b7 ,! t]m ,,nhsc p>ticipant 
means a ,national ,heal? ,s]vice ,corps 
memb] p>ticipat+ 9 ! ,national ,heal?   
,s]vice ,corps ,s*ol>%ip or ,loan       
,repaym5t ,program4  7e7 ,application ( 
provisions ,am\nts appropriat$ pursuant 
to ! am5dm5ts made by ?is section %all  
be subject to ! requirem5ts conta9$ 9   
,public ,law #aag-cbh = funds = programs
 au?oriz$ "u sections #ccj ?r\gh #cdj ( 
! ,public ,heal? ,s]vice ,act4  7f7     
,con=m+ am5dm5t ,p>agraph 7#d7 ( section
 #cjad7;h7 ( title #ah1 ,unit$ ,/ates   
,code1 is am5d$ by /rik+ & section      
#bcba7;d7 ( ! ,cont9u+ ,appropriations  

,act1 #bjbd & ,o!r ,ext5sions ,act &    
ins]t+ section #bcba7;d7 ( ! ,cont9u+   
,appropriations ,act1 #bjbd & ,o!r      
,ext5sions ,act1 & section #cja7;e7 ( ! 
,l[] ,co/s1 ,m ,transp>5cy ,act4  #cjb4 
,ext5sion ( special diabetes programs   
7a7 ,ext5sion ( special diabetes        
programs = type i diabetes ,section     
#ccj;,b7b77#b7 ( ! ,public ,heal?       
,s]vice ,act 7#db ,u4,s4,c4             
#bed;c-#b7;b77#b77 is am5d$-- 7#a7 9    
subp>agraph 7,d71 by /rik+ & at ! end2  
7#b7 9 subp>agraph 7,e71 by /rik+ !     
p]iod at ! end & ins]t+ a semicolon2 &  
7#c7 by add+ at ! end ! foll[+3  7,f7   
#abd1chc1efb = ! p]iod beg9n+ on ,janu>y
 #bj1 #bjbd1 & end+ on ,septemb] #cj1   
#bjbd1 to rema9 available until exp5d$2 
7,g7 #agj1jjj1jjj = fiscal ye> #bjbe1 to
 rema9 available until exp5d$2 &  7,h7  
#db1hdi1cae = ! p]iod beg9n+ ,octob] #a1
 #bjbe1 & end+ ,decemb] #ca1 #bjbe1 to  
rema9 available until exp5d$4  4  7b7   
,ext5d+ fund+ = special diabetes        
programs = ,indians ,section            

#ccj;,c7c77#b7 ( ! ,public ,heal?       
,s]vice ,act 7#db ,u4,s4,c4             
#bed;c-#c7;c77#b77 is am5d$--  7#a7 9   
subp>agraph 7,d71 by /rik+ & at ! end2  
7#b7 9 subp>agraph 7,e71 by /rik+ !     
p]iod at ! end & ins]t+ a semicolon2 &  
7#c7 by add+ at ! end ! foll[+3  7,f7   
#abd1chc1efb = ! p]iod beg9n+ on ,janu>y
 #bj1 #bjbd1 & end+ on ,septemb] #cj1   
#bjbd1 to rema9 available until exp5d$2 
7,g7 #agj1jjj1jjj = fiscal ye> #bjbe1 to
 rema9 available until exp5d$2 &  7,h7  
#db1hdi1cae = ! p]iod beg9n+ ,octob] #a1
 #bjbe1 & end+ ,decemb] #ca1 #bjbe1 to  
rema9 available until exp5d$4  4  #cjc4 
,delay+ c]ta9 disproportionate %>e      
paym5t cuts ,section #aibc7;f77#g77;,a7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acifr-#d7;f77#g77;,a77 is    
am5d$-- 7#a7 9 clause 7i7--  7,a7 by    
/rik+ ,= ! p]iod beg9n+ ,janu>y #bj1    
#bjbd1 & end+ ,septemb] #cj1 #bjbd1 & = 
ea* ( fiscal ye>s #bjbe & ins]t+ ,= ea* 
( fiscal ye>s #bjbf2 &  7,b7 by /rik+ or
 p]iod ea* place su* t]m appe>s2 &  7#b7

 9 clause 7ii71 by /rik+ = ! p]iod      
beg9n+ ,janu>y #bj1 #bjbd1 & end+       
,septemb] #cj1 #bjbd1 & = ea* ( fiscal  
ye>s #bjbe & ins]t+ = ea* ( fiscal ye>s 
#bjbf4  #cjd4 ,m$icaid improvem5t fund  
,section #aida7;b77#c77;,a7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acifw-#a7;b77#c77;,a77 is am5d$ by     
/rik+ #f1ceg1aag1haj & ins]t+ #j4  ,,iv 
,increas+ access to quality heal? data &
 l[]+ hidd5 fees  #dja4 ,increas+ ,plan 
,fiduci>ies' ,access to ,heal? ,data    
7a7 ,plan fiduci>y access to in=mation  
7#a7 ,9 g5]al ,p>agraph 7#b7 ( section  
#djh7;b7 ( ! ,employee ,retirem5t       
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aajh7;b77 is am5d$ by add+ at
 ! end ! foll[+ new subp>agraph3  7,c7  
,no contract or arrangem5t = s]vices    
betwe5 a gr\p heal? plan & any o!r      
entity1 includ+ a heal? c>e provid]     
7includ+ a heal? c>e facility71 network 
or association ( provid]s1 s]vice       
provid] (f]+ access to a network (      
provid]s1 ?ird-p>ty adm9i/rator1 or     

ph>macy b5efit manag]1 is reasonable )9 
! mean+ ( ?is p>agraph unless su*       
contract or arrangem5t--  7i7 all[s !   
responsible plan fiduci>y 7z def9$ 9    
subp>agraph 7,b77ii77,i77ee77 to audit  
or review all de-id5tifi$ claims &      
enc\nt] in=mation or data describ$ 9    
section #gbd7;a77#a77;,b7 to-- 7,i7     
ensure t su* entity complies ) ! t]ms ( 
! plan & any applicable law2 &  7,,ii7  
det]m9e ! reasonabl5ess ( comp5sation   
receiv$ by su* entity2 &  7ii7 does n-- 
7,i7 unreasonably limit ! numb] ( audits
 p]mitt$ dur+ a giv5 p]iod ( "t2  7,,ii7
 limit ! numb] ( de-id5tifi$ claims &   
enc\nt] in=mation or data t !           
responsible plan fiduci>y may access    
dur+ an audit2  7,,iii7 limit !         
disclosure ( pric+ t]ms = value-bas$    
paym5t arrangem5ts or capitat$ paym5t   
arrangem5ts1 includ+-- 7aa7 paym5t      
calculations & =mulas2  7bb7 quality    
measures2  7cc7 contract t]ms2  7dd7    
paym5t am\nts2  7ee7 measurem5t p]iods =
 all inc5tives2 &  7ff7 o!r paym5t      

me?odologies us$ by an entity1 includ+ a
 heal? c>e provid] 7includ+ a heal? c>e 
facility71 network or association (     
provid]s1 s]vice provid] (f]+ access to 
a network ( provid]s1 ?ird-p>ty         
adm9i/rator1 or ph>macy b5efit manag]2  
7,,iv7 limit ! disclosure ( ov]paym5ts &
 ov]paym5t recov]y t]ms2  7,v7 limit !  
"r ( ! responsible plan fiduci>y to     
select an auditor2  7,,vi7 o!rwise limit
 or unduly delay by great] ?an #fj      
cal5d> days aft] ! date ( reque/ !      
responsible plan fiduci>y f audit+ all  
de-id5tifi$ claims & enc\nt] in=mation  
or data2 or  7,,vii7 p]mit ! entity to  
*>ge a fee beyond ! reasonable direct   
co/s to provide ! requir$ in=mation &   
o!rwise comply & assi/ ) an audit       
reque/4  4  7#b7 ,civil en=cem5t  7,a7  
,9 g5]al ,subsection 7c7 ( section #ejb 
( su* ,act 7#bi ,u4,s4,c4 #aacb7 is     
am5d$ by add+ at ! end ! foll[+ new     
p>agraph3  7#ac7 ,9 ! case ( an agreem5t
 betwe5 a gr\p heal? plan & a heal? c>e 
provid] 7includ+ a heal? c>e facility71 

network or association ( provid]s1      
s]vice provid] (f]+ access to a network 
( provid]s1 ?ird-p>ty adm9i/rator1 or   
ph>macy b5efit manag]1 t violates !     
provisions ( section #gbd1 ! ,secret>y  
may assess a civil p5alty aga9/ su*     
provid]1 network or association1 s]vice 
provid] (f]+ access to a network (      
provid]s1 ?ird-p>ty adm9i/rator1 ph>macy
 b5efit manag]1 or o!r s]vice provid] 9 
! am\nt ( #aj1jjj = ea* day dur+ :i* su*
 violation cont9ues4 ,su* p5alty %all be
 9 addition to o!r p5alties z may be    
prescrib$ by law4  4  7,b7 ,con=m+      
am5dm5t ,p>agraph 7#f7 ( section        
#ejb7;a7 ( su* ,act is am5d$ by /rik+ or
 7#i7 & ins]t+ 7#i71 or 7#ac74  7#c7    
,exi/+ provisions void ,section #daj (  
su* ,act is am5d$ by add+ at ! end !    
foll[+ new subsection3  7c7 ,any        
provision 9 an agreem5t or in/rum5t %all
 be void z aga9/ public policy if su*   
provision--  7#a7 unduly delays or      
limits a plan fiduci>y f access+ !      
de-id5tifi$ claims & enc\nt] in=mation  

or data describ$ 9 section              
#gbd7;a77#a77;,b72 or  7#b7 violates !  
requirem5ts ( section #djh7;b77#b77;,c74
  4  7b7 ,updat$ atte/ation = price &   
quality in=mation ,section #gbd7;a77#c7 
( ! ,employee ,retirem5t ,income        
,security ,act 7#bi ,u4,s4,c4           
#aahem7a77#c77 is am5d$ to read z       
foll[s3  7#c7 ,atte/ation  7,a7 ,9 g5]al
 ,subject to subp>agraph 7,c71 ! plan   
fiduci>y ( a gr\p heal? plan or heal?   
insurance issu] (f]+ gr\p heal?         
insurance cov]age %all annually submit  
to ! ,secret>y an atte/ation t su* plan 
or issu] ( su* cov]age is 9 compliance )
 ! requirem5ts ( ?is subsection4 ,su*   
atte/ation %all also include a /atem5t  
v]ify+ t--  7i7 ! in=mation or data     
describ$ "u subp>agraphs 7,a7 & 7,b7 (  
p>agraph 7#a7 is available ^u reque/ &  
provid$ to ! plan fiduci>y1 ! plan      
adm9i/rator1 or ! issu] 9 a timely      
mann]2 &  7ii7 !re are no t]ms 9 !      
agreem5t "u su* p>agraph 7#a7 t directly
 or indirectly re/rict or unduly delay a

 plan fiduci>y1 ! plan adm9i/rator1 or !
 issu] f audit+1 review+1 or o!rwise    
access+ su* in=mation1 except z p]mitt$ 
"u section #djh7;b77#b77;,c74  7,b7     
,limitation on submission ,subject to   
clause 7ii71 a gr\p heal? plan or issu] 
(f]+ gr\p heal? insurance cov]age may n 
ent] into an agreem5t ) a ?ird-p>ty     
adm9i/rator or o!r s]vice provid] to    
submit ! atte/ation requir$ "u          
subp>agraph 7,a74  7,c7 ,exception ,9 ! 
case ( a gr\p heal? plan or issu] (f]+  
gr\p heal? insurance cov]age t is unable
 to obta9 ! in=mation or data ne$$ to   
submit ! atte/ation requir$ "u          
subp>agraph 7,a71 su* plan or issu] may 
submit a writt5 /atem5t 9 lieu ( su*    
atte/ation t includes--  7i7 an         
explanation ( :y su* plan or issu] 0    
unsuccessful 9 obta9+ su* in=mation or  
data1 includ+ :e!r su* plan or issu] 0  
limit$ or prev5t$ f audit+1 review+1 or 
o!rwise access+ su* in=mation or data2  
7ii7 a description ( ! ef=ts made by !  
plan fiduci>y to remove any gag clause  

provisions f ! agreem5t "u p>agraph     
7#a72 &  7iii7 a description ( any      
response by ! ?ird-p>ty adm9i/rator or  
o!r s]vice provid] ) respect to ef=ts to
 comply ) ! atte/ation requirem5t "u    
subp>agraph 7,a74  4  7c7 ,report on    
plan assets ,n lat] ?an #a ye> aft] !   
date ( enactm5t ( ?is ,act1 ! ,secret>y 
( ,labor %all submit to ! ,committee on 
,education & ! ,work=ce ( ! ,h\se (     
,repres5tatives & ! ,committee on       
,heal?1 ,education1 ,labor1 & ,p5sions (
 ! ,s5ate a report on ! /atus (         
de-id5tifi$ claims & enc\nt] in=mation  
or data describ$ 9 section              
#gbd7;a77#a77;,b7 ( ! ,employee         
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aahem71 includ+   
in=mation on ! foll[+3  7#a7 ,:e!r      
*anges to regulations or guidance w\ld  
p]mit su* in=mation or data to be deem$ 
a gr\p heal? plan asset 7z def9$ "u     
section #c7db7 ( su* ,act74  7#b7 ,:e!r 
re/rictions on ! ability ( a plan       
fiduci>y to access su* in=mation or data

 violates a requirem5t ( curr5t law4    
7#c7 ,! exi/+ regulatory au?ority ( !   
,secret>y to cl>ify :e!r su* in=mation  
or data is ! prop]ty ( a gr\p heal?     
plan1 r ?an a s]vice provid]4  7#d7     
,legislative recomm5dations to e/abli% t
 su* in=mation or data relat$ to a plan 
belongs to a gr\p heal? plan & is h&l$ 9
 ! be/ int]e/s ( plan p>ticipants &     
b5efici>ies4  7d7 ,effective date ,!    
am5dm5ts made by subsections 7a7 & 7b7  
%all apply ) respect to a plan beg9n+ ) 
! fir/ plan ye> t beg9s on or aft] !    
date t is #a ye> aft] ! date ( enactm5t 
( ?is ,act4  #djb4 ,hidd5 ,fees         
,disclosure ,requirem5ts  7a7           
,cl>ification ( ! application ( fee     
disclosure requirem5ts to cov]$ s]vice  
provid]s  7#a7 ,s]vices ,clause         
7ii77,i77bb7 ( section #djh7;b77#b77;,b7
 ( ! ,employee ,retirem5t ,income       
,security ,act ( #aigd 7#bi ,u4,s4,c4   
#aajh7;b77#b77;,b77 is am5d$--  7,a7 9  
subitem 7,,aa7 by /rik+ ,brok]age       
s]vices1 & ins]t+ ,s]vices 7includ+     

brok]age s]vices712 &  7,b7 9 subitem   
7,,bb7--  7i7 by /rik+ ,consult+1 &     
ins]t+ ,o!r s]vices12 &  7ii7 by ins]t+ 
any ( ! foll[+3 be=e plan design4  7#b7 
,disclosures ,clause 7iii77,,iii7 (     
section #djh7;b77#b77;,b7 ( ! ,employee 
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77
 is am5d$ by /rik+ 1 ei!r 9 ! aggregate 
or by s]vice1 & ins]t+ by s]vice4  7b7  
,/r5g!n+ disclosure requirem5ts )       
respect to ph>macy b5efit manag]s & ?ird
 p>ty adm9i/rators = gr\p heal? plans   
7#a7 ,c]ta9 arrangem5ts = ph>macy b5efit
 manag] s]vices consid]$ z indirect     
7,a7 ,9 g5]al ,clause 7i7 ( section     
#djh7;b77#b77;,b7 ( ! ,employee         
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77
 is am5d$--  7i7 by /rik+ requirem5ts ( 
?is clause & ins]t+ requirem5ts ( ?is   
subp>agraph2 &  7ii7 by add+ at ! end ! 
foll[+3 ,= purposes ( apply+ section    
#djf7;a77#a77;,c7 ) respect to a        
transaction describ$ "u ?is subp>agraph1

 a contract or arrangem5t = s]vices     
betwe5 a cov]$ plan & a heal? insurance 
issu] provid+ heal? insurance cov]age 9 
connection ) ! cov]$ plan 9 :i* ! heal? 
insurance issu] contracts1 9 connection 
) su* plan1 ) a s]vice provid] = ph>macy
 b5efit managem5t s]vices %all be       
consid]$ to con/itute an indirect       
furni%+ ( goods1 s]vices1 or facilities 
betwe5 ! plan & ! s]vice provid] act+ z 
! p>ty 9 int]e/44  7,b7 ,heal? insurance
 issu] & heal? insurance cov]age def9$  
,clause 7ii77,i77aa7 ( section          
#djh7;b77#b77;,b7 ( su* ,act 7#bi       
,u4,s4,c4 #aajh7;b77#b77;,b77 is am5d$  
by ins]t+ be=e ! p]iod at ! end & ! t]ms
 heal? insurance cov]age & heal?        
insurance issu] h ! mean+s giv5 su* t]ms
 9 section #gcc7;b74  7,c7 ,te*nical    
am5dm5t ,clause 7ii77,i77aa7 ( section  
#djh7;b77#b77;,b7 ( ! ,employee         
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77
 is fur!r am5d$ by ins]t+ 9 aft] def9$4 
7#b7 ,specific disclosure requirem5ts ) 

respect to ph>macy b5efit managem5t     
s]vices  7,a7 ,9 g5]al ,clause 7iii7 (  
section #djh7;b77#b77;,b7 ( su* ,act    
7#bi ,u4,s4,c4 #aajh7;b77#b77;,b77 is   
am5d$ by add+ at ! end ! foll[+3        
7,,vii7 ,) respect to a contract or     
arrangem5t ) ! cov]$ plan 9 connection )
 ! provision ( ph>macy b5efit managem5t 
s]vices1 z "p ( ! description requir$ "u
 subclauses 7,,iii7 & 7,,iv7--  7aa7 all
 comp5sation describ$ 9 clause          
7ii77,i77dd77,,aa71 includ+ fees1       
rebates1 alt]native disc\nts1 co-paym5t 
(fsets1 & o!r remun]ation expect$ to be 
receiv$ by ! cov]$ s]vice provid]1 an   
affiliate1 or a subcontractor f a       
ph>maceutical manufactur]1 di/ributor1  
rebate aggregator1 accumulator1 &       
maximiz]1 gr\p pur*as+ organization1 or 
any o!r ?ird p>ty2  7bb7 ! am\nt & =m ( 
any rebates1 disc\nts1 or price         
concessions1 includ+ ! am\nt expect$ to 
be pass$ ?r\gh to ! plan sponsor or !   
p>ticipants & b5efici>ies "u ! cov]$    
plan2  7cc7 all comp5sation expect$ to  

be receiv$ by ! cov]$ s]vice provid]1 an
 affiliate1 or a subcontractor z a      
result ( pay+ a l[] am\nt = ! drug ?an !
 am\nt *>g$ z a copaym5t1 co9surance    
am\nt1 or d$uctible2  7dd7 all          
comp5sation expect$ to be receiv$ by !  
cov]$ s]vice provid]1 an affiliate1 or a
 subcontractor z a result ( pay+        
ph>macies less ?an :at is *>g$ ! heal?  
plan1 plan sponsor1 or p>ticipants &    
b5efici>ies "u ! cov]$ plan2 &  7ee7 all
 comp5sation expect$ to be receiv$ by ! 
cov]$ s]vice provid]1 an affiliate1 or a
 subcontractor f drug manufactur]s & any
 o!r ?ird p>ty 9 ex*ange =-- 7,,aa7     
adm9i/]+1 invoic+1 allocat+1 or collect+
 rebates relat$ to ! cov]$ plan2 7,,bb7 
provid+ bus9ess s]vices & activities1   
includ+ provid+ access to drug          
utilization data2 7,,cc7 keep+ a        
p]c5tage ( ! li/ price ( a drug2 or     
7,,dd7 any o!r reason relat$ to ! role (
 a cov]$ s]vice provid] z a conduit     
betwe5 ! drug manufactur]s or any o!r   
?ird p>ty & ! cov]$ plan4  4  7,b7      

,annual disclosure ,clause 7v7 ( section
 #djh7;b77#b77;,b7 ( su* ,act 7#bi      
,u4,s4,c4 #aajh7;b77#b77;,b77 is am5d$  
by add+ at ! end ! foll[+3  7,,iii7 ,a  
cov]$ s]vice provid]1 ) respect to a    
contract or arrangem5t ) ! cov]$ plan 9 
connection ) provid+ ph>macy b5efit     
managem5t s]vices1 %all disclose1 on an 
annual basis n lat] ?an #fj days aft] ! 
beg9n+ ( ! curr5t plan ye>1 to a        
responsible plan fiduci>y1 9 writ+1 !   
foll[+ ) respect to ! twelve mon?s      
prec$+ ! curr5t plan ye>3 7aa7 ,all     
direct comp5sation describ$ 9 subclause 
7,,iii7 ( clause 7iii7 & indirect       
comp5sation describ$ 9 subclause 7,,iv7 
( clause 7iii7 receiv$ by ! cov]$ s]vice
 provid] 7includ+ su* comp5sation       
describ$ 9 subclause 7,,vii7 ( clause   
7iii774  7bb7 ,! total gross sp5d+ by ! 
cov]$ plan on drugs 7exclud+ rebates1   
disc\nts1 or o!r price concessions74    
7cc7 ,! total net sp5d+ by ! cov]$ plan 
on drugs4  7dd7 ,! total gross sp5d+ at 
all ph>macies :olly or p>tially own$ by 

! cov]$ s]vice provid] or any entity    
affiliat$ ) ! cov]$ s]vice provid]1     
includ+ mail-ord]1 specialty & retail   
ph>macies1 ) a breakd[n by individual   
ph>macy location4  7ee7 ,! aggregate    
am\nt ( clawback f su* ph>macies1       
includ+ mail-ord]1 specialty1 & retail  
ph>macies4 7,,aa7 categorical           
explanations 7gr\p$ by ! reason =       
clawback1 su* z contractual true-up     
provisions1 ov]paym5ts1 or non-cov]$    
m$ication disp5s$1 & includ+ in=mation  
on ! am\nt 9 ea* category t 0 pass$     
?r\gh to ! cov]$ plan & to p>ticipants &
 b5efici>ies ( ! cov]$ plan72 or 7,,bb7 
individual explanations = su* clawbacks4
  7ff7 ,total aggregate am\nts ( fees   
collect$ by ! cov]$ s]vice provid]1 an  
affiliate1 or a subcontractor 9         
connection ) ! provision ( ph>macy      
b5efit managem5t s]vices to ! cov]$     
plan4  7gg7 ,any o!r in=mation specifi$ 
by ! ,secret>y ?r\gh regulations or     
guidance t may be necess>y = a          
responsible plan fiduci>y to consid] !  

m]its ( ! contract or arrangem5t ) !    
cov]$ s]vice provid] & any conflicts (  
int]e/ t may exi/4  4  7,c7 ,ph>macy    
b5efit managem5t s]vices def9$ ,clause  
7ii77,i7 ( section #djh7;b77#b77;,b7 (  
su* ,act 7#bi ,u4,s4,c4                 
#aajh7;b77#b77;,b77 is am5d$ by add+ at 
! end ! foll[+3  7gg7 ,! t]m ph>macy    
b5efit managem5t s]vices includes any   
s]vices provid$ by a cov]$ s]vice       
provid] to a cov]$ plan ) respect to !  
adm9i/ration ( prescription drug b5efits
 "u ! cov]$ plan1 includ+-- 7,,aa7      
process+ & paym5t ( claims2 7,,bb7      
design ( ph>macy networks2 7,,cc7       
negotiation1 aggregation1 & di/ribution 
( rebates1 disc\nts1 & o!r price        
concessions2 7,,dd7 =mul>y design &     
ma9t5ance2 7,,ee7 op]ation ( ph>macies  
7:e!r retail1 mail ord]1 specialty drug1
 or o!rwise72 7,,ff7 recordkeep+2 7,,gg7
 utilization review2 7,,hh7 adjudication
 ( claims2 & 7,,ii7 any o!r s]vices     
specifi$ by ! ,secret>y ?r\gh guidance  
or rulemak+4  4  7,d7 ,clawback def9$   

,clause 7ii77,i7 ( section              
#djh7;b77#b77;,b7 ( su* ,act 7#bi       
,u4,s4,c4 #aajh7;b77#b77;,b771 z am5d$  
by subp>agraph 7,c71 is am5d$ by add+ at
 ! end ! foll[+3  7hh7 ,! t]m clawback  
means am\nts collect$ by a provid] (    
ph>macy b5efit managem5t s]vices f a    
ph>macy = copaym5ts collect$ f a        
p>ticipant or b5efici>y 9 excess ( !    
contract$ rate4  4  7#c7 ,specific      
disclosure requirem5ts ) respect to ?ird
 p>ty adm9i/ration s]vices = gr\p heal? 
plans  7,a7 ,9 g5]al ,clause 7iii7 (    
section #djh7;b77#b77;,b7 ( su* ,act    
7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 z   
am5d$ by p>agraph 7#b77;,a71 is fur!r   
am5d$ by add+ at ! end ! foll[+3        
7,,viii7 ,) respect to a contract or    
arrangem5t ) ! cov]$ plan 9 connection )
 ! provision ( ?ird p>ty adm9i/ration   
s]vices = gr\p heal? plans1 z "p ( !    
description requir$ "u subclauses       
7,,iii7 & 7,,iv7-- 7aa7 ! am\nt & =m (  
any rebates1 disc\nts1 sav+s fees1      
refunds1 or am\nts receiv$ f provid]s & 

facilities1 includ+ ! am\nts t w be     
reta9$ by ! cov]$ s]vice provid] z a    
fee2  7bb7 ! am\nt & =m ( fees expect$  
to be receiv$ f o!r s]vice provid]s 9   
relation to ! cov]$ plan1 includ+ !     
am\nts t w be reta9$ by ! cov]$ s]vice  
provid] z a fee2 &  7cc7 ! am\nt & =m ( 
expect$ recov]ies by ! cov]$ s]vice     
provid]1 includ+ ! am\nts t w be reta9$ 
by ! cov]$ s]vice provid] z a fee       
7disaggregat$ by category71 z a result  
(-- 7,,aa7 ov]paym5ts2 7,,bb7 errone\s  
paym5ts2 7,,cc7 unca%$ *ecks or         
incomplete paym5ts2 7,,dd7 bill+ errors2
 7,,ee7 subrogation2 7,,ff7 fraud2 or   
7,,gg7 any o!r reason on behalf ( !     
cov]$ plan4  4  7,b7 ,annual disclosure 
,clause 7v7 ( section #djh7;b77#b77;,b7 
( su* ,act 7#bi ,u4,s4,c4               
#aajh7;b77#b77;,b771 z am5d$ by p>agraph
 7#b77;,b71 is am5d$ by add+ at ! end ! 
foll[+3  7,,iv7 ,a cov]$ s]vice provid]1
 ) respect to a contract or arrangem5t )
 ! cov]$ plan 9 connection ) provid+    
?ird p>ty adm9i/ration s]vices = gr\p   

heal? plans1 %all disclose1 on an annual
 basis n lat] ?an #fj days aft] ! beg9n+
 ( ! curr5t plan ye>1 to a responsible  
plan fiduci>y1 9 writ+1 ! foll[+ )      
respect to ! twelve mon?s prec$+ !      
curr5t plan ye>3 7aa7 ,all direct       
comp5sation describ$ 9 subclause 7,,iii7
 ( clause 7iii74  7bb7 ,all indirect    
comp5sation describ$ 9 subclause 7,,iv7 
( clause 7iii7 receiv$ by ! cov]$ s]vice
 provid]1 an affiliate1 or a            
subcontractor 7includ+ su* comp5sation  
describ$ 9 subclause 7,,viii7 ( clause  
7iii774  7cc7 ,! aggregate am\nt = :i* !
 cov]$ s]vice provid]1 an affiliate1 or 
a subcontractor receiv$ indirect        
comp5sation & ! e/imat$ am\nt ( co/-%>+ 
incurr$ by plan p>ticipants &           
b5efici>ies z a result4  7dd7 ,! total  
gross sp5d+ by ! cov]$ plan on all co/s 
& fees aris+ "u or paid "u !            
adm9i/rative s]vices agreem5t ) ! cov]$ 
s]vice provid] 7n includ+ any am\nts    
describ$ 9 items 7aa7 ?r\gh 7cc7 (      
clause 7iii77,,viii774  7ee7 ,! total   

net sp5d+ by ! cov]$ plan on all co/s & 
fees aris+ "u or paid "u ! adm9i/rative 
s]vices agreem5t ) ! cov]$ s]vice       
provid]4  7ff7 ,! aggregate fees        
collect$ by ! cov]$ s]vice provid]1 an  
affiliate1 or a subcontractor4  7gg7    
,any o!r in=mation specifi$ by !        
,secret>y ?r\gh regulations or guidance 
t may be necess>y = a responsible plan  
fiduci>y to consid] ! m]its ( ! contract
 or arrangem5t ) ! cov]$ s]vice provid] 
& any conflicts ( int]e/ t may exi/4  4 
7,c7 ,?ird p>ty adm9i/ration s]vices =  
gr\p heal? plans def9$ ,clause 7ii77,i7 
( section #djh7;b77#b77;,b7 ( su* ,act  
7#bi ,u4,s4,c4 #aajh7;b77#b77;,b771 z   
am5d$ by p>agraph 7#b77;,c71 is am5d$ by
 add+ at ! end ! foll[+3  7ii7 ,! t]m   
?ird p>ty adm9i/ration s]vices = gr\p   
heal? plans includes any s]vices provid$
 by a cov]$ s]vice provid]1 an          
affiliate1 or a subcontractor to a cov]$
 plan ) respect to ! adm9i/ration (     
heal? b5efits "u ! cov]$ plan1 includ+--
 7,,aa7 ! process+1 repric+1 & paym5t ( 

claims2 7,,bb7 design1 creation1 &      
ma9t5ance ( provid] networks2 7,,cc7    
negotiation ( disc\nts (f gross rates2  
7,,dd7 b5efit & plan design2 7,,ee7     
negotiation ( paym5t rates2 7,,ff7      
recordkeep+2 7,,gg7 utilization review2 
7,,hh7 adjudication ( claims2 7,,ii7    
regulatory compliance2 & 7,,jj7 any o!r 
s]vices set =? 9 an adm9i/rative s]vices
 agreem5t or simil> agreem5t or specifi$
 by ! ,secret>y ?r\gh rulemak+4  4  7#d7
 ,rule ( con/ruction ,no?+ 9 ! am5dm5ts 
made by ?is section %all be con/ru$ to  
imply t a practice 9 relation to :i* a  
cov]$ s]vice provid] is requir$ to      
provide in=mation z a result ( su*      
am5dm5ts is p]missible "u ,f$]al law4   
7#e7 ,effective date ,no contract or    
arrangem5t ent]$ into prior to ,janu>y  
#a1 #bjbe1 %all be subject to !         
requirem5ts ( subsection 7b74  7c7      
,privacy requirem5ts ,section           
#djh7;b77#b7 ( ! ,employee ,retirem5t   
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aajh7;b77#b771 z am5d$ by    

section #dja1 is fur!r am5d$ by add+ at 
! end ! foll[+3  7,d7 ,privacy          
requirem5ts ,cov]$ s]vice provid]s %all 
provide in=mation "u subp>agraph 7,b7 9 
a mann] consi/5t ) ! privacy1 security1 
& brea* notification regulations        
promulgat$ "u section #acdjb7;a7 ( !    
,heal? ,in=mation ,te*nology = ,cl9ical 
,heal? ,act 7#db ,u4,s4,c4 #agicb7;a771 
& consi/5t ) ! ,,hipaa privacy          
regulations 7z def9$ 9 section          
#aahj7;b77#c7 ( ! ,social ,security     
,act7 & %all re/rict ! use & disclosure 
( su* in=mation accord+ to su* privacy1 
security1 & brea* notification          
regulations & su* ,,hipaa privacy       
regulations4  7,e7 ,disclosure &        
r$isclosure  7i7 ,limitation to bus9ess 
associates ,a responsible plan fiduci>y 
receiv+ in=mation disclos$ "u           
subp>agraph 7,b7 may disclose su*       
in=mation only to ! entity f :i* !      
in=mation 0 receiv$1 ! gr\p heal? plan =
 :i* ! in=mation p]ta9s1 or to t        
entity's bus9ess associates z def9$ 9   

section #afj4ajc ( title #de1 ,code (   
,f$]al ,regulations 7or successor       
regulations7 or z p]mitt$ by ! ,,hipaa  
,privacy ,rule 7#de ,,cfr p>ts #afj &   
#afd1 subp>ts ,a & ,e74  7ii7           
,cl>ification reg>d+ public disclosure (
 in=mation ,no?+ 9 ?is section %all     
prev5t a gr\p heal? plan or heal?       
insurance issu] (f]+ gr\p heal?         
insurance cov]age1 or a cov]$ s]vice    
provid]1 f plac+ reasonable re/rictions 
on ! public disclosure ( ! in=mation    
describ$ 9 ?is subp>agraph1 except t su*
 plan1 issu]1 or entity may n re/rict   
disclosure ( su* in=mation to !         
,dep>tm5t ( ,labor4  7,f7 ,additional   
privacy requirem5ts  7i7 ,9 g5]al ,cov]$
 s]vice provid]s %all ensure t in=mation
 provid$ "u subp>agraph 7,b7 conta9s    
only summ>y heal? in=mation1 z def9$ 9  
section #afd4ejd7;a7 ( title #de1 ,code 
( ,f$]al ,regulations 7or successor     
regulations74  7ii7 ,re/rictions ,a gr\p
 heal? plan mu/ comply ) section        
#afd4ejd7;f7 ( title #de1 ,code ( ,f$]al

 ,regulations & a responsible plan      
adm9i/rator :o is a plan sponsor mu/ act
 9 accordance ) ! t]ms ( ! agreem5t     
describ$ 9 su* section4  7,g7 ,rule (   
con/ruction ,no?+ 9 ?is section %all be 
con/ru$ to modify ! requirem5ts = !     
creation1 receipt1 ma9t5ance1 or        
transmission ( protect$ heal? in=mation 
"u ! ,,hipaa privacy regulations 7z     
def9$ 9 section #aahj7;b77#c7 ( !       
,social ,security ,act74  4  7d7        
,implem5tation ,n lat] ?an #a ye> aft] !
 date ( enactm5t ( ?is ,act1 ! ,secret>y
 ( ,labor %all issue notice & comm5t    
rulemak+ z necess>y to implem5t !       
provisions ( ?is section4 ,! ,secret>y  
%all ensure t su* rulemak+--  7#a7      
acc\nts = ! v>i$ comp5sation practices (
 cov]$ s]vice provid]s 7z def9$ "u      
section #djh7;b77#b77;,b72 &  7#b7      
e/abli%es /&>ds = ! disclosure ( expect$
 comp5sation by su* cov]$ s]vice        
provid]s4  #djc4 ,prescription drug     
price in=mation requirem5t  7a7 ,,phsa  
7#a7 ,9 g5]al ,"p ,d ( title ,,xxvii ( !

 ,public ,heal? ,s]vice ,act1 z am5d$ by
 section #ajf1 is fur!r am5d$ by add+ at
 ! end ! foll[+ new section3            
#bgii;,a-#ab4 ,in=mation on prescription
 drugs  7a7 ,9 g5]al ,a gr\p heal? plan 
or a heal? insurance issu] (f]+ gr\p or 
individual heal? insurance cov]age      
%all--  7#a7 n re/rict1 directly or     
indirectly1 any ph>macy t disp5ses a    
prescription drug to an enrollee 9 !    
plan or cov]age f in=m+ 7or p5alize su* 
ph>macy = in=m+7 an enrollee ( any      
diff]5tial betwe5 ! enrollee'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 gr\p   
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 an enrollee ( any  
diff]5tial betwe5 ! enrollee's          
out-(-pocket co/ "u su* plan or cov]age 
) respect to acquisition ( ! drug & !   
am\nt an individual w\ld pay =          
acquisition ( ! drug )\t us+ any gr\p   
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 ! enrollee "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  7#b7 ,con=m+   
am5dm5t ,section #bgbi ( ! ,public      
,heal? ,s]vice ,act 7#db ,u4,s4,c4      
#cjj;gg-#bi7 is am5d$ by add+ at ! end !
 foll[+ new subsection3  7c7 ,sunset ,! 
prec$+ provisions ( ?is section %all n  
apply beg9n+ on ! date ( ! enactm5t (   
?is subsection4  4  7b7 ,,erisa  7#a7 ,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 #ajf1 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 or 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 gr\p   
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 su* plan or cov]age ) respect to
 acquisition ( ! drug & ! am\nt an      
individual w\ld pay = acquisition ( !   
drug )\t us+ any gr\p 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  7#b7 ,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 #ajf1
 is fur!r am5d$ by ins]t+ aft] ! item   
relat+ to section #gbf ! foll[+ new     
item3  ,sec4 #gbg4 ,in=mation on        
prescription drugs4  4  7c7 ,,irc  7#a7 
,9 g5]al ,sub*apt] ,b ( *apt] #ajj ( !  

,int]nal ,rev5ue ,code ( #aihf1 z am5d$ 
by section #ajf1 is fur!r am5d$ by add+ 
at ! end ! foll[+3  #ihbg4 ,in=mation on
 prescription drugs  7a7 ,9 g5]al ,a    
gr\p heal? plan %all-- 7#a7 n re/rict1  
directly or indirectly1 any ph>macy t   
disp5ses a prescription drug to a       
p>ticipant or b5efici>y 9 ! plan 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 ) respect to 
acquisition ( ! drug & ! am\nt an       
individual w\ld pay = acquisition ( !   
drug )\t us+ any gr\p 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* plan 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 ) respect to acquisition 
( ! drug & ! am\nt an individual w\ld   
pay = acquisition ( ! drug )\t us+ any  
gr\p 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 ! plan1 includ+ any co/-%>+
 7includ+ any d$uctible1 copaym5t1 or   
co9surance7 &1 z det]m9$ by ! ,secret>y1
 any o!r exp5diture4  4  7#b7 ,cl]ical  
am5dm5t ,! table ( sections = sub*apt]  
,b ( *apt] #ajj ( ! ,int]nal ,rev5ue    
,code ( #aihf1 z am5d$ by section #ajf1 
is fur!r am5d$ by add+ at ! end ! foll[+
 new item3  ,sec4 #ihbg4 ,in=mation on  
prescription drugs4  4  #djd4           
,implem5tation fund+  7a7 ,9 g5]al ,= ! 
purposes describ$ 9 subsection 7b71 & 9 
addition to am\nts o!rwise available =  
su* purposes !re are appropriat$1 out ( 
am\nts 9 ! ,treasury n o!rwise          
appropriat$1 to ! ,secret>y ( ,labor    
#ce1jjj1jjj1 = fiscal ye> #bjbd1 to     

rema9 available ?r\gh fiscal ye> #bjbi4 
7b7 ,p]mitt$ purposes ,! purposes       
describ$ 9 ?is subsection are limit$ to 
! foll[+ purposes1 ins(> z su* purposes 
are to c>ry out ! provisions (1 includ+ 
! am5dm5ts made by1 title ,i & ,,iv3    
7#a7 ,prep>+1 draft+1 & issu+ propos$ & 
f9al regulations or int]im regulations4 
7#b7 ,prep>+1 draft+1 & issu+ guidance &
 public in=mation4  7#c7 ,prep>+1       
draft+1 & publi%+ reports4  7#d7        
,en=cem5t ( su* provisions4  7#e7       
,report+1 collection1 & analysis ( data4
  7#f7 ,o!r adm9i/rative duties necess>y
 = implem5tation ( su* provisions4  7c7 
,transp>5cy ( implem5tation funds ,!    
,secret>y ( ,labor %all annually submit1
 no lat] ?an ,septemb] #a/ ( ea* ye>1 to
 ! ,committees on ,education & ,work=ce 
& on ,appropriations ( ! ,h\se (        
,repres5tatives & ! ,committees on      
,heal?1 ,education1 ,labor1 & ,p5sions &
 on ,appropriations ( ! ,s5ate a report 
on funds exp5d$ pursuant to funds       
appropriat$ "u ?is section4  ,pass$ !   

,h\se ( ,repres5tatives ,decemb] #aa1   
#bjbc4;,cl]k4