,i  #aai? ,,congress  #a/ ,session  ,h4 
,r4 #feja  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,decemb] #i1 #bjbe,mr4
 ,fitzpatrick 7= himself1 ,mr4 ,gold5 ( 
,ma9e1 ,mr4 ,bacon1 ,mr4 ,suozzi1 ,mr4  
,bresnahan1 ,mr4 ,davis ( ,nor? ,c>ol9a1
 ,ms4 ,malliotakis1 ,ms4 ,p]ez1 ,mr4    
,lawl]1 ,ms4 ,salaz>1 ,mr4 ,mack5zie1   
,mr4 ,kean1 ,mr4 ,van ,drew1 ,mr4       
,valadao1 ,mr4 ,ciscomani1 & ,mr4       
,la,lota7 introduc$ ! foll[+ bill2 :i* 0
 ref]r$ to ! ,committee on ,en]gy &     
,comm]ce1 & 9 addition to ! ,committees 
on ,ways & ,means1 & ,education &       
,work=ce1 = a p]iod to be subsequ5tly   
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d ! ,int]nal ,rev5ue    
,code ( #aihf to ext5d & modify !       
enhanc$ premium tax cr$it1 to am5d !    
,pati5t ,protection & ,af=dable ,c>e    
,act to make c]ta9 adju/m5ts to !       
op]ation ( ! ,ex*anges e/abli%$ "u su*  
,act1 & = o!r purposes4  #a4 ,%ort title

 ,?is ,act may be cit$ z ! ,bip>tisan   
,heal? ,insurance ,af=dability ,act4    
#b4 ,ext5sion & modification ( enhanc$  
premium tax cr$it  7a7 ,ext5sion &      
modification ( rules ,to increase       
premium assi/ance am\nts ,section       
#cf;,b7b77#c77;,a77iii7 ( ! ,int]nal    
,rev5ue ,code ( #aihf is am5d$--  7#a7  
by r$esignat+ subclauses 7,i7 & 7,,ii7 z
 items 7aa7 & 7bb71 respectively1 &     
adju/+ ! m>g9s accord+ly1  7#b7 by /rik+
 ,tempor>y p]c5tages = #bjba ?r\gh      
#bjbe4--;,9 ! case ( & ins]t+  ,tempor>y
 rules = c]ta9 ye>s4--  7,i7  ,be=e     
#bjbf  ,9 ! case (  1 &  7#c7 by add+ at
 ! end ! foll[+3  7,,ii7  ,aft] #bjbe = 
taxpay]s ^: h\sehold income does n exce$
 #aej p]c5t ( pov]ty l9e  ,9 ! case ( a 
taxable ye> beg9n+ aft] ,decemb] #ca1   
#bjbe1 & be=e ,janu>y #a1 #bjbh1 if any 
taxpay]'s h\sehold income does n exce$  
#aej p]c5t ( ! pov]ty l9e = su* taxable 
ye>1 ! premium assi/ance am\nt det]m9$  
"u subsection 7b77#b71 ) respect to any 
cov]age mon?1 is ! excess ( ! less] ( ! 

am\nt describ$ 9 p>agraph 7#b77;,a7 or !
 am\nt describ$ 9 p>agraph 7#b77;,b77i71
 ov] #e4  7,,iii7  ,aft] #bjbe =        
taxpay]s ^: h\sehold income does n exce$
 #bjj p]c5t ( pov]ty l9e  ,9 ! case ( a 
taxable ye> beg9n+ aft] ,decemb] #ca1   
#bjbe1 & be=e ,janu>y #a1 #bjbh1 if any 
taxpay]'s h\sehold income exce$s #aej   
p]c5t ( ! pov]ty l9e b does n exce$ #bjj
 p]c5t ( ! pov]ty l9e = su* taxable ye>1
 ! premium assi/ance am\nt det]m9$ "u   
subsection 7b77#b71 ) respect to any    
cov]age mon?1 %all be su* t ! premium   
assi/ance am\nt = su* a taxpay] %all    
decrease1 on a slid+ scale 9 a l9e>     
mann]1 f ! am\nt t w\ld result if       
det]m9$ 9 accordance ) subclause 7,,ii7 
to ! am\nt t w\ld result "u subsection  
7b77#b7 by sub/itut+ #b p]c5t = !       
applicable p]c5tage 9 subp>agraph       
7,b77ii7 !re(4  7,,iv7  ,aft] #bjbe =   
taxpay]s ^: h\sehold income exce$s #bjj 
p]c5t ( pov]ty l9e  ,9 ! case ( a       
taxable ye> beg9n+ aft] ,decemb] #ca1   
#bjbe1 & be=e ,janu>y #a1 #bjbh1 if any 

taxpay]'s h\sehold income exce$s #bjj   
p]c5t ( ! pov]ty l9e = su* taxable ye>--
  7aa7 clause 7ii7 %all n apply =       
purposes ( adju/+ premium p]c5tages "u  
?is subp>agraph1 &  7bb7 ! foll[+ table 
%all be appli$ 9 lieu ( ! table conta9$ 
9 clause 7i73  ,9 ! case ( h\sehold     
income 7express$ z a p]c5t ( pov]ty l9e7
 )9 ! foll[+ income ti]3 ,! initial     
premium p]c5tage is- ,! f9al premium    
p]c5tage is-  #bjj up to #bej #b4j #d4j 
#bej up to #cjj #d4j #f4j  #cjj up to   
#djj #f4j #h4e  #djj up to #fjj #h4e    
#h4e  #fjj up to #gjj #h4e #i4be  4  7b7
  ,ext5sion & modification ( rule ,to   
all[ cr$it to taxpay]s ^: h\sehold      
income exce$s #djj p]c5t ( pov]ty l9e   
,section #cf;,b7c77#a77;,e7 ( su* ,code 
is am5d$--  7#a7 by /rik+ ,tempor>y rule
 = #bjba ?r\gh #bjbe4--;,9 ! case ( &   
ins]t+  ,tempor>y rule = c]ta9 ye>s4--  
7i7  ,be=e #bjbf  ,9 ! case (  1 &  7#b7
 by add+ at ! end ! foll[+3  7ii7  ,aft]
 #bjbe  ,9 ! case ( a taxable ye> beg9n+
 aft] ,decemb] #ca1 #bjbe1 & be=e       

,janu>y #a1 #bjbh1 subp>agraph 7,a7 %all
 be appli$ by sub/itut+ b does n exce$  
#gjj p]c5t = b does n exce$ #djj p]c5t4 
4  7c7 ,effective date ,! am5dm5ts made 
by ?is section %all apply to taxable    
ye>s beg9n+ aft] ,decemb] #ca1 #bjbe4   
#c4 ,gu>drails to prev5t fraud 9        
,ex*anges  7a7 ,r$uction ( fraudul5t    
enrollm5t 9 qualifi$ heal? plans  7#a7  
,p5alties = ag5ts & brok]s ,section     
#adaa7;h77#a7 ( ! ,pati5t ,protection & 
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjha7;h77#a77 is am5d$-- 7,a7 9       
subp>agraph 7,a7-- 7i7 by r$esignat+    
clause 7ii7 z clause 7iv72  7ii7 9      
clause 7i7-- 7,i7 9 ! matt] prec$+      
subclause 7,i71 by /rik+ ,if-- & all t  
foll[s ?r\gh ! su* p]son 9 ! matt]      
foll[+ subclause 7,,ii7 & ins]t+ !      
foll[+3 ,if any p]son 7o!r ?an an ag5t  
or brok]7 fails to provide correct      
in=mation "u subsection 7b7 & su*       
failure is attributable to neglig5ce or 
disreg>d ( any rules or regulations ( ! 
,secret>y1 su* p]son2 &  7,,ii7 9 !     

second s5t5ce1 by /rik+ ,= purposes &   
ins]t+ ! foll[+3  7iii7 ,def9itions (   
neglig5ce1 disreg>d ,= purposes  2      
7iii7 by ins]t+ aft] clause 7i7 !       
foll[+3  7ii7 ,civil p5alties = c]ta9   
violations by ag5ts or brok]s ,if any   
ag5t or brok] fails to provide correct  
in=mation "u subsection 7b7 or section  
#acaa7;c77#h7 or o!r in=mation1 z       
specifi$ by ! ,secret>y1 & su* failure  
is attributable to neglig5ce or disreg>d
 ( any rules or regulations ( !         
,secret>y1 su* ag5t or brok] %all be    
subject1 9 addition to any o!r p5alties 
t may be prescrib$ by law1 includ+      
subp>agraph 7,c71 to a civil p5alty ( n 
less ?an #aj1jjj & n m ?an #ej1jjj )    
respect to ea* individual :o is !       
subject ( an application = :i* su*      
incorrect in=mation is provid$4  2 &    
7iv7 9 clause 7iv7 7z s r$esignat$71 by 
ins]t+ or 7ii7 aft] clause 7i72  7,b7 9 
subp>agraph 7,b7-- 7i7 by ins]t+ includ+
 subp>agraph 7,c71 aft] law12  7ii7 by  
/rik+ ,any p]son & ins]t+ ! foll[+3  7i7

 ,9 g5]al ,any p]son  2 &  7iii7 by add+
 at ! end ! foll[+3  7ii7 ,civil        
p5alties = kn[+ violations by ag5ts or  
brok]s  7,i7 ,9 g5]al ,any ag5t or brok]
 :o kn[+ly provides false or fraudul5t  
in=mation "u subsection 7b7 or section  
#acaa7;c77#h71 or o!r false or fraudul5t
 in=mation z "p ( an application =      
enrollm5t 9 a qualifi$ heal? plan (f]$  
?r\gh an ,ex*ange1 z specifi$ by !      
,secret>y1 %all be subject1 9 addition  
to any o!r p5alties t may be prescrib$  
by law1 includ+ subp>agraph 7,c71 to a  
civil p5alty ( n m ?an #bjj1jjj )       
respect to ea* individual :o is !       
subject ( an application = :i* su* false
 or fraudul5t in=mation is provid$4     
7,,ii7 ,proc$ure ,! provisions ( section
 #aabh;,a ( ! ,social ,security ,act    
7o!r ?an subsections 7a7 & 7b7 ( su*    
section7 %all apply to a civil monet>y  
p5alty "u subclause 7,i7 9 ! same mann] 
z su* provisions apply to a p5alty or   
proce$+ "u section #aabh;,a ( ! ,social 
,security ,act4  2 &  7,c7 by add+ at ! 

end ! foll[+3  7,c7 ,crim9al p5alties   
,any ag5t or brok] :o kn[+ly & willfully
 provides false or fraudul5t in=mation  
"u subsection 7b7 or section            
#acaa7;c77#h71 or o!r false or fraudul5t
 in=mation z "p ( an application =      
enrollm5t 9 a qualifi$ heal? plan (f]$  
?r\gh an ,ex*ange1 z specifi$ by !      
,secret>y1 %all be f9$ "u title #ah1    
,unit$ ,/ates ,code1 imprison$ = n m ?an
 #aj ye>s1 or bo?4  4  7#b7 ,consum]    
protections  7,a7 ,9 g5]al ,section     
#acaa7;c7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjca7;c77 is am5d$ by add+ at ! end ! 
foll[+ new p>agraph3  7#h7 ,ag5t- or    
brok]-assi/$ enrollm5t 9 qualifi$ heal? 
plans 9 c]ta9 ex*anges  7,a7 ,9 g5]al ,=
 plan ye>s beg9n+ on or aft] su* date   
specifi$ by ! ,secret>y1 b n lat] ?an   
,janu>y #a1 #bjbi1 9 ! case ( an        
,ex*ange t ! ,secret>y op]ates pursuant 
to section #acba7;c77#a71 ! ,secret>y   
%all e/abli% a v]ification process = new
 enrollm5ts ( individuals 91 & *anges 9 

cov]age = individuals "u1 a qualifi$    
heal? plan (f]$ ?r\gh su* ,ex*ange1 :i* 
are submitt$ by an ag5t or brok] 9      
accordance ) section #acab7;e7 & = :i* !
 ag5t or brok] is eligible to receive a 
commission4  7,b7 ,requirem5ts ,!       
enrollm5t v]ification process "u        
subp>agraph 7,a7 %all include-- 7i7 a   
requirem5t t ! ag5t or brok] provide ) !
 new enrollm5t or cov]age *ange su*     
docum5tation or evid5ce 7su* z a /&>diz$
 cons5t =m7 or o!r s\rces z ! ,secret>y 
det]m9es necess>y to e/abli% t ! ag5t or
 brok] has ! cons5t ( ! individual = !  
new enrollm5t or cov]age *ange2  7ii7 a 
requirem5t t any commissions due to a   
brok] or ag5t = su* new enrollm5t or    
cov]age *ange are paid aft] ! enrollee  
has resolv$ all inconsi/5cies 9         
accordance ) p>agraphs 7#c7 & 7#d7 (    
section #adaa7;e72  7iii7 a requirem5t t
 ! in=mation requir$ "u clause 7i7 &1 z 
applicable1 ! date on :i* inconsi/5cies 
are resolv$ z describ$ 9 clause 7ii71 is
 accessible to ! applicable qualifi$    

heal? plan ?r\gh a database or o!r      
res\rce1 z det]m9$ by ! ,secret>y1 s t  
any commissions due to a brok] or ag5t =
 su* enrollm5t c be effectuat$ at !     
appropriate "t2  7iv7 a requirem5t t    
individuals are notifi$ ( any *anges to 
enrollm5t1 cov]age1 ! ag5t ( record1 or 
premium tax cr$its 9 a timely mann] & t 
su* notice provides pla9 language       
in/ructions on h[ individuals c cancel  
unau?oriz$ activity2  7v7 a requirem5t t
 individuals be able to access _! acc\nt
 in=mation on a website or o!r te*nology
 plat=m1 z def9$ by ! ,secret>y1 :5 us$ 
to submit an enrollm5t or plan *ange1 9 
lieu ( ! ,ex*ange website describ$ 9    
subsection 7d77#d77;,c71 includ+        
in=mation on ! ag5t ( record1 ! qualifi$
 heal? plan1 & :5 any *anges are made to
 ! ag5t ( record or ! qualifi$ heal?    
plan1 on a consum]-fac+ website or ?r\gh
 a toll-free telephone hotl9e2 &  7vi7 a
 requirem5t t ! ag5t or brok] report to 
! ,secret>y any ?ird-p>ty m>ket+        
organization or field m>ket+            

organization 7z su* t]ms are def9$ 9    
section #acab7;e77 involv$ 9 ! *a9 (    
enrollm5t 7z s def9$7 ) respect to su*  
new enrollm5t or cov]age *ange4  7,c7   
,consum] protection ,! ,secret>y %all   
ensure t ! enrollm5t v]ification process
 "u subp>agraph 7,a7 prioritizes        
cont9uity ( cov]age & c>e = individuals1
 includ+ by n dis5roll+ individuals f a 
qualifi$ heal? plan )\t ! cons5t ( !    
individual1 reg>dless ( :e!r ! brok]1   
ag5t1 or qualifi$ heal? plan is 9       
violation ( any requirem5t "u ?is       
p>agraph4  4  7,b7 ,requir$ report+     
,section #acaa7;c77#a7 ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjca7;c77#a77 is am5d$-- 7i7
 9 subp>agraph 7,h71 by /rik+ & at !    
end2  7ii7 9 subp>agraph 7,i71 by /rik+ 
! p]iod at ! end & ins]t+ 2 &2 &  7iii7 
by add+ at ! end ! foll[+3  7,j7 report 
to ! ,secret>y ! t]m9ation 7z def9$ 9   
section #acab7;e77#a77;,c77 ( an issu]4 
4  7#c7 ,au?ority to regulate field     
m>ket+ organizations & ?ird-p>ty m>ket+ 

organizations ,section #acab7;e7 ( !    
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjcb7;e77 is      
am5d$-- 7,a7 by r$esignat+ p>agraphs    
7#a7 & 7#b7 z subclauses 7,i7 & 7,,ii71 
respectively1 & adju/+ ! m>g9s          
accord+ly2  7,b7 9 subclause 7,,ii7 7z s
 r$esignat$71 by /rik+ ! p]iod at ! end 
& ins]t+ 2 &2  7,c7 by /rik+ !          
subsection designation & head+ & all t  
foll[s ?r\gh brok]s-- & ins]t+ ! foll[+3
  7e7 ,regulation ( ag5ts1 brok]s1 &    
c]ta9 m>ket+ organizations  7#a7 ,ag5ts1
 brok]s1 & c]ta9 m>ket+ organizations   
7,a7 ,9 g5]al ,! ,secret>y %all e/abli% 
proc$ures "u :i* a ,/ate may all[-- 7i7 
ag5ts or brok]s--  2 &  7,d7 by add+ at 
! end ! foll[+3  7ii7 field m>ket+      
organizations & ?ird-p>ty m>ket+        
organizations to p>ticipate 9 ! *a9 (   
enrollm5t = an individual ) respect to  
qualifi$ heal? plans (f]$ ?r\gh an      
,ex*ange4  7,b7 ,crit]ia ,= plan ye>s   
beg9n+ on or aft] su* date specifi$ by !
 ,secret>y1 b n lat] ?an ,janu>y #a1    

#bjbi1 ! ,secret>y1 by regulation1 %all 
e/abli% crit]ia = ,/ates to use 9       
det]m9+ :e!r to all[ ag5ts & brok]s to  
enroll individuals & employ]s 9 qualifi$
 heal? plans z describ$ 9 subclause 7,i7
 ( subp>agraph 7,a77i7 & to assi/       
individuals z describ$ 9 subclause      
7,,ii7 ( su* subp>agraph & field m>ket+ 
organizations & ?ird-p>ty m>ket+        
organizations to p>ticipate 9 ! *a9 (   
enrollm5t z describ$ 9 subp>agraph      
7,a77ii74 ,su* crit]ia %all1 at a       
m9imum1 require t-- 7i7 an ag5t or brok]
 act 9 accordance ) a /&>d ( conduct t  
includes a duty ( su* ag5t or brok] to  
act 9 ! be/ int]e/s ( ! enrollee2  7ii7 
a field m>ket+ organization or ?ird-p>ty
 m>ket+ organization agree to report !  
t]m9ation ( an ag5t or brok] to !       
applicable ,/ate & ! ,secret>y1 includ+ 
! reason = t]m9ation2 &  7iii7 an ag5t1 
brok]1 field m>ket+ organization1 or    
?ird-p>ty m>ket+ organization-- 7,i7    
meet su* m>ket+ requirem5ts z are       
requir$ by ! ,secret>y2  7,,ii7 meet    

m>ket+ requirem5ts 9 accordance ) o!r   
applicable ,f$]al or ,/ate law2  7,,iii7
 does n employ practices t are confus+  
or mislead+1 z det]m9$ by ! ,secret>y2  
7,,iv7 submit all m>ket+ mat]ials to !  
,secret>y =1 z det]m9$ appropriate by ! 
,secret>y1 review & approval2  7,v7 is a
 lic5s$ ag5t or brok] or meets o!r      
lic5sure requirem5ts1 z requir$ by !    
,/ate2  7,,vi7 regi/] ) ! ,secret>y2 &  
7,,vii7 does n comp5sate any individual 
or organization = ref]rals or any o!r   
s]vice relat+ to ! sale (1 m>ket+ =1 or 
enrollm5t 9 qualifi$ heal? plans unless 
su* individual or organization meets !  
crit]ia describ$ 9 subclauses 7,i7 ?r\gh
 7,,vi74  7,c7 ,def9itions ,9 ?is       
p>agraph3 7i7 ,*a9 ( enrollm5t ,! t]m   
*a9 ( enrollm5t1 ) respect to enrollm5t 
( an individual 9 a qualifi$ heal? plan 
(f]$ ?r\gh an ,ex*ange1 means any /eps  
tak5 f m>ket+ to su* individual1 to su* 
individual mak+ an enrollm5t decision ) 
respect to su* a plan4  7ii7 ,field     
m>ket+ organization ,! t]m field m>ket+ 

organization means an organization or   
individual t directly employs or        
contracts ) ag5ts & brok]s1 or contracts
 ) c>ri]s1 to provide functions relat+  
to enrollm5t ( individuals 9 qualifi$   
heal? plans (f]$ ?r\gh an ,ex*ange z "p 
( ! *a9 ( enrollm5t4  7iii7 ,m>ket+ ,!  
t]m m>ket+ means ! use ( m>ket+ mat]ials
 to provide in=mation to curr5t &       
prospective enrollees 9 a qualifi$ heal?
 plan (f]$ ?r\gh an ,ex*ange4  7iv7     
,m>ket+ mat]ials ,! t]m m>ket+ mat]ials 
means mat]ials relat+ to a qualifi$     
heal? plan (f]$ ?r\gh an ,ex*ange or    
b5efits (f]$ ?r\gh an ,ex*ange t-- 7,i7 
are int5d$-- 7aa7 to draw an            
individual's att5tion to su* plan or !  
premium tax cr$its or co/-%>+ r$uctions 
= su* plan or plans (f]$ ?r\gh an       
,ex*ange2  7bb7 to influ5ce an          
individual's decision-mak+ process :5   
select+ a qualifi$ heal? plan 9 :i* to  
enroll2 or  7cc7 to influ5ce an         
enrollee's decision to /ay enroll$ 9 su*
 plan2 &  7,,ii7 include or address     

cont5t reg>d+ ! b5efits1 b5efit         
/ructure1 premiums1 or co/ %>+ ( su*    
plan4  7v7 ,t]m9ation ,! t]m t]m9ation1 
) respect to a contract or bus9ess      
arrangem5t betwe5 an ag5t or brok] & a  
field m>ket+ organization1 ?ird-p>ty    
m>ket+ organization1 or heal? insurance 
issu]1 means-- 7,i7 ! end+ ( su*        
contract or bus9ess arrangem5t1 ei!r    
unilat]ally by "o ( ! p>ties or on      
mutual agreem5t2 or  7,,ii7 ! expiration
 ( su* contract or bus9ess arrangem5t t 
is n replac$ by a sub/antially simil>   
agreem5t4  7vi7 ,?ird-p>ty m>ket+       
organization ,! t]m ?ird-p>ty m>ket+    
organization means an organization or   
individual t is comp5sat$ to p]=m lead  
g5]ation1 m>ket+1 or sales relat+ to    
enrollm5t ( individuals 9 qualifi$ heal?
 plans (f]$ ?r\gh an ,ex*ange z "p ( !  
*a9 ( enrollm5t4  4  7#d7 ,transp>5cy   
,section #acab7;e7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjcb7;e771 z am5d$ by       
p>agraph 7#c71 is fur!r am5d$ by add+ at

 ! end ! foll[+ new p>agraphs3  7#b7    
,audits  7,a7 ,9 g5]al ,= plan ye>s     
beg9n+ on or aft] su* date specifi$ by !
 ,secret>y1 b n lat] ?an ,janu>y #a1    
#bjbi1 ! ,secret>y1 9 coord9ation ) !   
,/ates & 9 consultation ) ! ,national   
,association ( ,insurance ,commission]s1
 %all implem5t a process = ! ov]sight & 
en=cem5t ( ag5t & brok] compliance ) ?is
 section & o!r applicable ,f$]al & ,/ate
 law 7includ+ regulations7 t %all       
include-- 7i7 p]iodic audits ( ag5ts &  
brok]s bas$ on-- 7,i7 compla9ts fil$ ) !
 ,secret>y by individuals enroll$ by su*
 an ag5t or brok] 9 a qualifi$ heal?    
plan (f]$ ?r\gh an ,ex*ange2  7,,ii7 an 
incid5t or enrollm5t patt]n t sugge/s   
fraud2 &  7,,iii7 o!r factors det]m9$ by
 ! ,secret>y2 &  7ii7 a process "u :i* !
 ,secret>y %all %>e audit results & ref]
 pot5tial cases ( fraud to ! relevant   
,/ate dep>tm5t ( insurance4  7,b7       
,effect ,no?+ 9 ?is p>agraph limits or  
re/ricts any ref]rals made "u section   
#acaa7;i77#c7 or any en=cem5t actions "u

 section #adaa7;h74  7#c7 ,li/ ,!       
,secret>y %all develop a process to     
regul>ly provide to qualifi$ heal?      
plans1 ,ex*anges1 & ,/ates a li/ (      
susp5d$ & t]m9at$ ag5ts & brok]s4  4    
7b7 ,removal ( deceas$ individuals f    
,ex*ange plans ,section #acaa7;c7 ( !   
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjca7;c771 z am5d$
 by subsection 7a71 is fur!r am5d$ by   
add+ at ! end ! foll[+ new p>agraph3    
7#i7 ,removal ( deceas$ individuals f   
,ex*ange plans  7,a7 ,9 g5]al ,n lat]   
?an #ij days aft] ! date ( ! enactm5t ( 
?is p>agraph1 & on a qu>t]ly basis      
!reaft]1 ! ,secret>y %all conduct a *eck
 ( ! ,dea? ,ma/] ,file 7z su* t]m is    
def9$ 9 section #bjc7;d7 ( ! ,bip>tisan 
,budget ,act ( #bjac7 = purposes (      
id5tify+ individuals enroll$ 9 a        
qualifi$ heal? plan ?r\gh an ,ex*ange :o
 are deceas$4  7,b7 ,process ,!         
,secret>y %all-- 7i7 e/abli% a process  
to v]ify t an individual id5tifi$       
pursuant to a *eck describ$ 9           

subp>agraph 7,a7 is deceas$2 &  7ii7    
require an ,ex*ange to t]m9ate su*      
individual's enrollm5t "u a qualifi$    
heal? plan4  4  7c7 ,/&>d ( pro( =      
t]m9at+ ag5ts & brok]s ,section         
#acab7;e7 ( ! ,pati5t ,protection &     
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjcb7;e771 z am5d$ by subsection 7a71 
is fur!r am5d$ by add+ at ! end ! foll[+
 new p>agraph3  7#d7 ,/&>d = t]m9ation =
 c]ta9 ,ex*anges ,9 ! case ( an ag5t or 
brok] ) an agreem5t 9 effect ) an       
,ex*ange op]at$ by ! ,secret>y pursuant 
to section #acba7;c7 to p]=m activities 
describ$ 9 p>agraph 7#a77;,a77i7 )      
respect to su* ,ex*ange1 ! ,secret>y may
 t]m9ate su* agreem5t = cause if !      
,secret>y f9ds1 bas$ on a prepond]ance (
 ! evid5ce1 t su* ag5t or brok] has     
violat$ su* agreem5t1 o!rwise applicable
 law1 or any o!r requirem5t applicable  
to su* ag5t or brok]4  4  7d7           
,requirem5t = ,ex*ange ,to notify       
individuals ( value ( premium tax cr$its
 ,section #adab7;c77#b7 ( ! ,pati5t     

,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjhb7;c77#b77 is am5d$ by   
add+ at ! end ! foll[+ new subp>agraph3 
7,c7  ,ex*ange responsibilities  ,beg9n+
 ,janu>y #a1 #bjbg1 if an ,ex*ange is   
notifi$ "u p>agraph 7#a7 ( an advance   
det]m9ation "u section #adaa ) respect  
to ! eligibility ( an individual = a    
premium tax cr$it "u section #cf;,b ( ! 
,int]nal ,rev5ue ,code ( #aihf1 !       
,ex*ange %all1 prior to enroll+ su*     
individual 9 a qualifi$ heal? plan1     
cle>ly notify su* individual ( ! am\nt (
 su* tax cr$it4  4  #d4 ,ext5d+ annual  
op5 enrollm5t p]iod = ,ex*anges = plan  
ye> #bjbf ,! ,secret>y ( ,heal? & ,human
 ,s]vices %all revise section           
#aee4daj7;e7 ( title #de1 ,code ( ,f$]al
 ,regulations 7or any successor         
regulation7 to provide t ! annual op5   
enrollm5t p]iod det]m9$ = plan ye> #bjbf
 pursuant to section #acaa7;c77#f7 ( !  
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahjca7;c77#f77 %all
 beg9 on ,novemb] #a1 #bjbe1 & end on   

,m>* #a1 #bjbf4  #e4 ,mod]niz+ & ,ensur+
 ,,pbm ,acc\ntability  7a7 ,9 g5]al     
7#a7 ,prescription drug plans ,section  
#ahfj;,d-#ab ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciew-#aab7 is am5d$ by 
add+ at ! end ! foll[+ new subsection3  
7h7 ,requirem5ts relat+ to ph>macy      
b5efit manag]s ,= plan ye>s beg9n+ on or
 aft] ,janu>y #a1 #bjbi3 7#a7 ,agreem5ts
 ) ph>macy b5efit manag]s ,ea* contract 
ent]$ into ) a ,,pdp sponsor "u ?is "p )
 respect to a prescription drug plan    
(f]$ by su* sponsor %all provide t any  
ph>macy b5efit manag] act+ on behalf (  
su* sponsor has a writt5 agreem5t ) !   
,,pdp sponsor "u :i* ! ph>macy b5efit   
manag]1 & any affiliates ( su* ph>macy  
b5efit manag]1 z applicable1 agree to   
meet ! foll[+ requirem5ts3 7,a7 ,no     
income o!r ?an bona fide s]vice fees    
7i7 ,9 g5]al ,! ph>macy b5efit manag] & 
any affiliate ( su* ph>macy b5efit      
manag] %all n d]ive any remun]ation )   
respect to any s]vices provid$ on behalf
 ( any entity or individual1 9          

connection ) ! utilization ( cov]$ "p ,d
 drugs1 f any su* entity or individual  
o!r ?an bona fide s]vice fees1 subject  
to clauses 7ii7 & 7iii74  7ii7 ,inc5tive
 paym5ts ,= ! purposes ( ?is subsection1
 an inc5tive paym5t 7z det]m9$ by !     
,secret>y7 paid by a ,,pdp sponsor to a 
ph>macy b5efit manag] t is p]=m+ s]vices
 on behalf ( su* sponsor %all be deem$ a
 bona fide s]vice fee 7ev5 if su* paym5t
 does n o!rwise meet ! def9ition ( su*  
t]m "u p>agraph 7#g77;,b77 if su* paym5t
 is a flat doll> am\nt1 is consi/5t )   
fair m>ket value 7z specifi$ by !       
,secret>y71 is relat$ to s]vices        
actually p]=m$ by ! ph>macy b5efit      
manag] or affiliate ( su* ph>macy b5efit
 manag]1 on behalf ( ! ,,pdp sponsor    
mak+ su* paym5t1 9 connection ) !       
utilization ( cov]$ "p ,d drugs1 & meets
 additional requirem5ts1 if any1 z      
det]m9$ appropriate by ! ,secret>y4     
7iii7 ,cl>ification on rebates &        
disc\nts us$ to l[] co/s = cov]$ "p d   
drugs ,rebates1 disc\nts1 & o!r price   

concessions receiv$ by a ph>macy b5efit 
manag] or an affiliate ( a ph>macy      
b5efit manag] f manufactur]s1 ev5 if su*
 price concessions are calculat$ z a    
p]c5tage ( a drug's price1 %all n be    
consid]$ a violation ( ! requirem5ts (  
clause 7i7 if !y are fully pass$ ?r\gh  
to a ,,pdp sponsor & are compliant ) all
 regulatory & subregulatory requirem5ts 
relat$ to direct & indirect remun]ation 
= manufactur] rebates "u ?is "p1 includ+
 9 cases :]e a ,,pdp sponsor is act+ z a
 ph>macy b5efit manag] on behalf ( a    
prescription drug plan (f]$ by su* ,,pdp
 sponsor4  7iv7 ,evaluation (           
remun]ation arrangem5ts ,compon5ts (    
subsets ( remun]ation arrangem5ts 7su* z
 fees or o!r =ms ( comp5sation paid to  
or reta9$ by ! ph>macy b5efit manag] or 
affiliate ( su* ph>macy b5efit manag]71 
z det]m9$ appropriate by ! ,secret>y1   
betwe5 ph>macy b5efit manag]s or        
affiliates ( su* ph>macy b5efit manag]s1
 z applicable1 & o!r entities involv$ 9 
! disp5s+ or utilization ( cov]$ "p ,d  

drugs 7includ+ ,,pdp sponsors1          
manufactur]s1 ph>macies1 & o!r entities 
z det]m9$ appropriate by ! ,secret>y7   
%all be subject to review by !          
,secret>y1 9 consultation ) ! ,(fice ( !
 ,inspector ,g5]al ( ! ,dep>tm5t (      
,heal? & ,human ,s]vices1 z det]m9$     
appropriate by ! ,secret>y4 ,!          
,secret>y1 9 consultation ) ! ,(fice ( !
 ,inspector ,g5]al1 %all review :e!r    
remun]ation "u su* arrangem5ts is       
consi/5t ) fair m>ket value 7z specifi$ 
by ! ,secret>y7 ?r\gh reviews &         
assessm5ts ( su* remun]ation1 z det]m9$ 
appropriate4  7v7 ,disgorgem5t ,!       
ph>macy b5efit manag] %all disgorge any 
remun]ation paid to su* ph>macy b5efit  
manag] or an affiliate ( su* ph>macy    
b5efit manag] 9 violation ( ?is         
subp>agraph to ! ,,pdp sponsor4  7vi7   
,additional requirem5ts ,! ph>macy      
b5efit manag] %all-- 7,i7 ent] into a   
writt5 agreem5t ) any affiliate ( su*   
ph>macy b5efit manag]1 "u :i* !         
affiliate %all id5tify & disgorge any   

remun]ation describ$ 9 clause 7v7 to !  
ph>macy b5efit manag]2 &  7,,ii7 atte/1 
subject to any requirem5ts det]m9$      
appropriate by ! ,secret>y1 t ! ph>macy 
b5efit manag] has ent]$ into a writt5   
agreem5t describ$ 9 subclause 7,i7 ) any
 relevant affiliate ( ! ph>macy b5efit  
manag]4  7,b7 ,transp>5cy reg>d+        
gu>antees & co/ p]=mance evaluations ,! 
ph>macy b5efit manag] %all-- 7i7 def9e1 
int]pret1 & apply1 9 a fully transp>5t &
 consi/5t mann] = purposes ( calculat+  
or o!rwise evaluat+ ph>macy b5efit      
manag] p]=mance aga9/ pric+ gu>antees or
 simil> co/ p]=mance measurem5ts relat$ 
to rebates1 disc\nts1 price concessions1
 or net co/s1 t]ms su* z-- 7,i7 g5]ic   
drug1 9 a mann] consi/5t ) ! def9ition (
 ! t]m "u section #dbc4d ( title #db1   
,code ( ,f$]al ,regulations1 or a       
successor regulation2  7,,ii7 br& "n    
drug1 9 a mann] consi/5t ) ! def9ition (
 ! t]m "u section #dbc4d ( title #db1   
,code ( ,f$]al ,regulations1 or a       
successor regulation2  7,,iii7 specialty

 drug2  7,,iv7 rebate2 &  7,v7 disc\nt2 
7ii7 id5tify any drugs1 claims1 or price
 concessions exclud$ f any pric+        
gu>antee or o!r co/ p]=mance measure 9 a
 cle> & consi/5t mann]2 &  7iii7 :]e a  
pric+ gu>antee or o!r co/ p]=mance      
measure is bas$ on a pric+ b5*m>k o!r   
?an ! :olesale acquisition co/ 7z def9$ 
9 section #ahdg;,a7c77#f77;,b77 ( a     
drug1 calculate & provide a :olesale    
acquisition co/-bas$ equival5t to !     
pric+ gu>antee or o!r co/ p]=mance      
measure4  7,c7 ,provision ( in=mation   
7i7 ,9 g5]al ,n lat] ?an ,july #a ( ea* 
ye>1 beg9n+ 9 #bjbi1 ! ph>macy b5efit   
manag] %all submit to ! ,,pdp sponsor1 &
 to ! ,secret>y1 a report1 9 accordance 
) ?is subp>agraph1 & %all make su*      
report available to su* sponsor at no   
co/ to su* sponsor 9 a =mat specifi$ by 
! ,secret>y "u p>agraph 7#e74 ,ea* su*  
report %all include1 ) respect to su*   
,,pdp sponsor & ea* plan (f]$ by su*    
sponsor1 ! foll[+ in=mation ) respect to
 ! previ\s plan ye>3 7,i7 ,a li/ ( all  

drugs cov]$ by ! plan t 7 disp5s$       
includ+1 ) respect to ea* su* drug--    
7aa7 ! br& "n1 g5]ic or non-propriet>y  
"n1 & ,national ,drug ,code2  7bb7 !    
numb] ( plan enrollees = :om ! drug 0   
disp5s$1 ! total numb] ( prescription   
claims = ! drug 7includ+ orig9al        
prescriptions & refills1 c\nt$ z sep>ate
 claims71 & ! total numb] ( dosage units
 ( ! drug disp5s$2  7cc7 ! numb] (      
prescription claims describ$ 9 item 7bb7
 by ea* type ( disp5s+ *annel ?r\gh :i* 
! drug 0 disp5s$1 includ+ retail1 mail  
ord]1 specialty ph>macy1 long t]m c>e   
ph>macy1 home infusion ph>macy1 or o!r  
types ( ph>macies or provid]s2  7dd7 !  
av]age :olesale acquisition co/1 li/$ z 
co/ p] day's supply1 co/ p] dosage unit1
 & co/ p] typical c\rse ( treatm5t 7z   
applicable72  7ee7 ! av]age :olesale    
price = ! drug1 li/$ z price p] day's   
supply1 price p] dosage unit1 & price p]
 typical c\rse ( treatm5t 7z            
applicable72  7ff7 ! total out-(-pocket 
sp5d+ by plan enrollees on su* drug aft]

 application ( any b5efits "u ! plan1   
includ+ plan enrollee sp5d+ ?r\gh       
copaym5ts1 co9surance1 & d$uctibles2    
7gg7 total rebates paid by ! manufactur]
 on ! drug z report$ "u ! ,detail$ ,,dir
 ,report 7or any successor report7      
submitt$ by su* sponsor to ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices2  7hh7 all   
o!r direct or indirect remun]ation on ! 
drug z report$ "u ! ,detail$ ,,dir      
,report 7or any successor report7       
submitt$ by su* sponsor to ! ,c5t]s =   
,m$ic>e  ,m$icaid ,s]vices2  7ii7 !     
av]age ph>macy reimbursem5t am\nt paid  
by ! plan = ! drug 9 ! aggregate &      
disaggregat$ by disp5s+ *annel id5tifi$ 
9 item 7cc72  7jj7 ! av]age ,national   
,av]age ,drug ,acquisition ,co/         
7,,nadac72 &  7kk7 total                
manufactur]-d]iv$ rev5ue1 inclusive (   
bona fide s]vice fees1 attributable to !
 drug & reta9$ by ! ph>macy b5efit      
manag] & any affiliate ( su* ph>macy    
b5efit manag]4  7,,ii7 ,9 ! case ( a    
ph>macy b5efit manag] t has an affiliate

 t is a retail1 mail ord]1 or specialty 
ph>macy1 ) respect to drugs cov]$ by su*
 plan t 7 disp5s$1 ! foll[+ in=mation3  
7aa7 ,! p]c5tage ( total prescriptions t
 7 disp5s$ by ph>macies t are an        
affiliate ( ! ph>macy b5efit manag] =   
ea* drug4  7bb7 ,! int]qu>tile range ( !
 total comb9$ co/s paid by ! plan & plan
 enrollees1 p] dosage unit1 p] c\rse (  
treatm5t1 p] #cj-;day supply1 & p]      
#ij-;day supply = ea* drug disp5s$ by   
ph>macies t are n an affiliate ( !      
ph>macy b5efit manag] & t are includ$ 9 
! ph>macy network ( su* plan4  7cc7 ,!  
int]qu>tile range ( ! total comb9$ co/s 
paid by ! plan & plan enrollees1 p]     
dosage unit1 p] c\rse ( treatm5t1 p]    
#cj-;day supply1 & p] #ij-;day supply = 
ea* drug disp5s$ by ph>macies t are an  
affiliate ( ! ph>macy b5efit manag] & t 
are includ$ 9 ! ph>macy network ( su*   
plan4  7dd7 ,! l[e/ total comb9$ co/    
paid by ! plan & plan enrollees1 p]     
dosage unit1 p] c\rse ( treatm5t1 p]    
#cj-;day supply1 & p] #ij-;day supply1 =

 ea* drug t is available f any ph>macy  
includ$ 9 ! ph>macy network ( su* plan4 
7ee7 ,! diff]5ce betwe5 ! av]age        
acquisition co/ ( ! affiliate1 su* z a  
ph>macy or o!r entity t acquires        
prescription drugs1 t initially acquires
 ! drug & ! am\nt report$ "u subclause  
7,i77jj7 = ea* drug4  7ff7 ,a li/       
inclusive ( ! br& "n1 g5]ic or          
non-propriet>y "n1 & ,national ,drug    
,code ( cov]$ "p ,d drugs subject to an 
agreem5t ) a cov]$ entity "u section    
#cdj;,b ( ! ,public ,heal? ,s]vice ,act 
= :i* ! ph>macy b5efit manag] or an     
affiliate ( ! ph>macy b5efit manag] _h a
 contract or o!r arrangem5t ) su* a     
cov]$ entity 9 ! s]vice area ( su* plan4
  7,,iii7 ,:]e a drug approv$ "u section
 #eje7;c7 ( ! ,f$]al ,food1 ,drug1 &    
,cosmetic ,act 7ref]r$ to 9 ?is         
subclause z ! li/$ drug7 is cov]$ by !  
plan1 ! foll[+ in=mation3 7aa7 ,a li/ ( 
curr5tly m>ket$ g5]ic drugs approv$ "u  
section #eje7;j7 ( ! ,f$]al ,food1      
,drug1 & ,cosmetic ,act pursuant to an  

application t ref]5ces su* li/$ drug t  
are n cov]$ by ! plan1 are cov]$ on !   
same =mul>y ti] or a =mul>y ti]         
typically associat$ ) high] co/-%>+ ?an 
! li/$ drug1 or are subject to          
utilization managem5t t ! li/$ drug is n
 subject to4  7bb7 ,! e/imat$ av]age    
b5efici>y co/-%>+ "u ! plan = a #cj-;day
 supply ( ! li/$ drug4  7cc7 ,:]e a     
g5]ic drug li/$ "u item 7aa7 is on a    
=mul>y ti] typically associat$ ) high]  
co/-%>+ ?an ! li/$ drug1 ! e/imat$      
av]age co/-%>+ t a b5efici>y w\ld h paid
 = a #cj-;day supply ( ea* ( ! g5]ic    
drugs describ$ 9 item 7aa71 _h ! plan   
provid$ cov]age = su* drugs on ! same   
=mul>y ti] z ! li/$ drug4  7dd7 ,a      
writt5 ju/ification = provid+ m         
favorable cov]age ( ! li/$ drug ?an !   
g5]ic drugs describ$ 9 item 7aa74  7ee7 
,! numb] ( curr5tly m>ket$ g5]ic drugs  
approv$ "u section #eje7;j7 ( ! ,f$]al  
,food1 ,drug1 & ,cosmetic ,act pursuant 
to an application t ref]5ces su* li/$   
drug4  7,,iv7 ,:]e a ref]5ce product 7z 

def9$ 9 section #cea7;i7 ( ! ,public    
,heal? ,s]vice ,act7 is cov]$ by ! plan1
 ! foll[+ in=mation3 7aa7 ,a li/ (      
curr5tly m>ket$ biosimil> biological    
products lic5s$ "u section #cea7k7 ( !  
,public ,heal? ,s]vice ,act pursuant to 
an application t ref]s to su* ref]5ce   
product t are n cov]$ by ! plan1 are    
cov]$ on ! same =mul>y ti] or a =mul>y  
ti] typically associat$ ) high] co/-%>+ 
?an ! ref]5ce product1 or are subject to
 utilization managem5t t ! ref]5ce      
product is n subject to4  7bb7 ,!       
e/imat$ av]age b5efici>y co/-%>+ "u !   
plan = a #cj-;day supply ( ! ref]5ce    
product4  7cc7 ,:]e a biosimil>         
biological product li/$ "u item 7aa7 is 
on a =mul>y ti] typically associat$ )   
high] co/-%>+ ?an ! ref]5ce product1 !  
e/imat$ av]age co/-%>+ t a b5efici>y    
w\ld h paid = a #cj-;day supply ( ea* ( 
! biosimil> biological products describ$
 9 item 7aa71 _h ! plan provid$ cov]age 
= su* products on ! same =mul>y ti] z ! 
ref]5ce product4  7dd7 ,a writt5        

ju/ification = provid+ m favorable      
cov]age ( ! ref]5ce product ?an !       
biosimil> biological product describ$ 9 
item 7aa74  7ee7 ,! numb] ( curr5tly    
m>ket$ biosimil> biological products    
lic5s$ "u section #cea7k7 ( ! ,public   
,heal? ,s]vice ,act1 pursuant to an     
application t ref]s to su* ref]5ce      
product4  7,v7 ,total gross sp5d+ on    
cov]$ "p ,d drugs by ! plan1 n net (    
rebates1 fees1 disc\nts1 or o!r direct  
or indirect remun]ation4  7,,vi7 ,!     
total am\nt reta9$ by ! ph>macy b5efit  
manag] or an affiliate ( su* ph>macy    
b5efit manag] 9 rev5ue relat$ to        
utilization ( cov]$ "p ,d drugs "u t    
plan1 inclusive ( bona fide s]vice fees4
  7,,vii7 ,! total sp5d+ on cov]$ "p ,d 
drugs net ( rebates1 fees1 disc\nts1 or 
o!r direct & indirect remun]ation by !  
plan4  7,,viii7 ,an explanation ( any   
b5efit design p>amet]s "u su* plan t    
enc\rage plan enrollees to fill         
prescriptions at ph>macies t are an     
affiliate ( su* ph>macy b5efit manag]1  

su* z mail & specialty home deliv]y     
programs1 & retail & mail auto-refill   
programs4  7,,ix7 ,! foll[+ in=mation3  
7aa7 ,a li/ ( all brok]s1 consultants1  
advisors1 & auditors t receive          
comp5sation f ! ph>macy b5efit manag] or
 an affiliate ( su* ph>macy b5efit      
manag] = ref]rals1 consult+1 audit+1 or 
o!r s]vices (f]$ to ,,pdp sponsors      
relat$ to ph>macy b5efit managem5t      
s]vices4  7bb7 ,! am\nt ( comp5sation   
provid$ by su* ph>macy b5efit manag] or 
affiliate to ea* su* brok]1 consultant1 
advisor1 & auditor4  7cc7 ,! me?odology 
= calculat+ ! am\nt ( comp5sation       
provid$ by su* ph>macy b5efit manag] or 
affiliate1 = ea* su* brok]1 consultant1 
advisor1 & auditor4  7,x7 ,a li/ ( all  
affiliates ( ! ph>macy b5efit manag]4   
7,,xi7 ,a summ>y docum5t submitt$ 9 a   
/&>diz$ template develop$ by ! ,secret>y
 t includes su* in=mation describ$ 9    
subclauses 7,i7 ?r\gh 7,x74  7ii7       
,writt5 explanation ( contracts or      
agreem5ts ) drug manufactur]s  7,i7 ,9  

g5]al ,! ph>macy b5efit manag] %all1 n  
lat] ?an #cj days aft] ! f9alization (  
any contract or agreem5t betwe5 su*     
ph>macy b5efit manag] or an affiliate ( 
su* ph>macy b5efit manag] & a drug      
manufactur] 7or subsidi>y1 ag5t1 or     
entity affiliat$ ) su* drug manufactur]7
 t makes rebates1 disc\nts1 paym5ts1 or 
o!r f9ancial inc5tives relat$ to "o or m
 cov]$ "p ,d drugs or o!r prescription  
drugs1 z applicable1 ( ! manufactur]    
directly or indirectly cont+5t ^u       
cov]age1 =mul>y placem5t1 or utilization
 managem5t conditions on any o!r cov]$  
"p ,d drugs or o!r prescription drugs1 z
 applicable1 submit to ! ,,pdp sponsor a
 writt5 explanation ( su* contract or   
agreem5t4  7,,ii7 ,requirem5ts ,a writt5
 explanation "u subclause 7,i7 %all--   
7aa7 include ! manufactur] subject to ! 
contract or agreem5t1 all cov]$ "p ,d   
drugs & o!r prescription drugs1 z       
applicable1 subject to ! contract or    
agreem5t & ! manufactur]s ( su* drugs1 &
 a high-level description ( ! t]ms ( su*

 contract or agreem5t & h[ su* t]ms     
apply to su* drugs2 &  7bb7 be c]tifi$  
by ! ,*ief ,executive ,(fic]1 ,*ief     
,f9ancial ,(fic]1 or ,g5]al ,c\nsel (   
su* ph>macy b5efit manag]1 or affiliate 
( su* ph>macy b5efit manag]1 z          
applicable1 or an individual delegat$ ) 
! au?ority to sign on behalf ( "o ( ^!  
(fic]s1 :o reports directly to ! (fic]4 
7,,iii7 ,def9ition ( o!r prescription   
drugs ,= purposes ( ?is clause1 ! t]m   
o!r prescription drugs means            
prescription drugs cov]$ z supplem5tal  
b5efits "u ?is "p or prescription drugs 
paid outside ( ?is "p4  7,d7 ,audit     
rights  7i7 ,9 g5]al ,n less ?an once a 
ye>1 at ! reque/ ( ! ,,pdp sponsor1 !   
ph>macy b5efit manag] %all all[ = an    
audit ( ! ph>macy b5efit manag] to      
ensure compliance ) all t]ms &          
conditions "u ! writt5 agreem5t describ$
 9 ?is p>agraph & ! accuracy ( in=mation
 report$ "u subp>agraph 7,c74  7ii7     
,auditor ,! ,,pdp sponsor %all h ! "r to
 select an auditor4 ,! ph>macy b5efit   

manag] %all n impose any limitations on 
! selection ( su* auditor4  7iii7       
,provision ( in=mation ,! ph>macy b5efit
 manag] %all make available to su*      
auditor all records1 data1 contracts1 & 
o!r in=mation necess>y to confirm !     
accuracy ( in=mation provid$ "u         
subp>agraph 7,c71 subject to reasonable 
re/rictions on h[ su* in=mation mu/ be  
report$ to prev5t r$isclosure ( su*     
in=mation4  7iv7 ,tim+ ,! ph>macy b5efit
 manag] mu/ provide in=mation "u clause 
7iii7 & o!r in=mation1 data1 & records  
relevant to ! audit to su* auditor )9 #f
 mon?s ( ! initiation ( ! audit &       
respond to reque/s = additional         
in=mation f su* auditor )9 #cj days aft]
 ! reque/ = additional in=mation4  7v7  
,in=mation f affiliates ,! ph>macy      
b5efit manag] %all be responsible =     
provid+ to su* auditor in=mation requir$
 to be report$ "u subp>agraph 7,c7 or "u
 clause 7iii7 ( ?is subp>agraph t is    
own$ or held by an affiliate ( su*      
ph>macy b5efit manag]4  7#b7 ,en=cem5t  

7,a7 ,9 g5]al ,ea* ,,pdp sponsor %all-- 
7i7 disgorge to ! ,secret>y any am\nts  
disgorg$ to ! ,,pdp sponsor by a ph>macy
 b5efit manag] "u p>agraph 7#a77;,a77v72
  7ii7 require1 9 a writt5 agreem5t )   
any ph>macy b5efit manag] act+ on behalf
 ( su* sponsor or affiliate ( su*       
ph>macy b5efit manag]1 t su* ph>macy    
b5efit manag] or affiliate reimburse !  
,,pdp sponsor = any civil money p5alty  
impos$ on ! ,,pdp sponsor z a result ( !
 failure ( ! ph>macy b5efit manag] or   
affiliate to meet ! requirem5ts (       
p>agraph 7#a7 t are applicable to !     
ph>macy b5efit manag] or affiliate "u ! 
agreem5t2 &  7iii7 require1 9 a writt5  
agreem5t ) any su* ph>macy b5efit manag]
 act+ on behalf ( su* sponsor or        
affiliate ( su* ph>macy b5efit manag]1 t
 su* ph>macy b5efit manag] or affiliate 
be subject to punitive rem$ies = brea* (
 contract = failure to comply ) !       
requirem5ts applicable "u p>agraph 7#a74
  7,b7 ,report+ ( alleg$ violations ,!  
,secret>y %all make available & ma9ta9 a

 me*anism = manufactur]s1 ,,pdp         
sponsors1 ph>macies1 & o!r entities t h 
contractual relation%ips ) ph>macy      
b5efit manag]s or affiliates ( su*      
ph>macy b5efit manag]s to report1 on a  
confid5tial basis1 alleg$ violations (  
p>agraph 7#a77;,a7 or subp>agraph 7,c74 
7,c7 ,anti-retaliation & anti-co]cion   
,consi/5t ) applicable ,f$]al or ,/ate  
law1 a ,,pdp sponsor %all n-- 7i7       
retaliate aga9/ an individual or entity 
= report+ an alleg$ violation "u        
subp>agraph 7,b72 or  7ii7 co]ce1       
intimidate1 ?reat51 or int]f]e ) !      
ability ( an individual or entity to    
report any su* alleg$ violations4  7#c7 
,c]tification ( compliance  7,a7 ,9     
g5]al ,ea* ,,pdp sponsor %all furni% to 
! ,secret>y 7at a "t & 9 a mann]        
specifi$ by ! ,secret>y7 an annual      
c]tification ( compliance ) ?is         
subsection1 z well z su* in=mation z !  
,secret>y det]m9es necess>y to c>ry out 
?is subsection4  7,b7 ,implem5tation    
,not)/&+ any o!r provision ( law1 !     

,secret>y may implem5t ?is p>agraph by  
program in/ruction or o!rwise4  7#d7    
,rule ( con/ruction ,no?+ 9 ?is         
subsection %all be con/ru$ z-- 7,a7     
prohibit+ flat disp5s+ fees or          
reimbursem5t or paym5t = +r$i5t co/s    
7includ+ cu/om>y1 indu/ry-/&>d disc\nts 
directly relat$ to drug acquisition t   
are reta9$ by ph>macies or :olesal]s7 to
 entities t acquire or disp5se          
prescription drugs2 or  7,b7 modify+    
regulatory requirem5ts or sub-regulatory
 program in/ruction or guidance relat$  
to ph>macy paym5t1 reimbursem5t1 or     
disp5s+ fees4  7#e7 ,/&>d =mats  7,a7 ,9
 g5]al ,n lat] ?an ,june #a1 #bjbh1 !   
,secret>y %all specify /&>d1            
ma*9e-readable =mats = ph>macy b5efit   
manag]s to submit annual reports requir$
 "u p>agraph 7#a77;,c77i74  7,b7        
,implem5tation ,not)/&+ any o!r         
provision ( law1 ! ,secret>y may        
implem5t ?is p>agraph by program        
in/ruction or o!rwise4  7#f7            
,confid5tiality  7,a7 ,9 g5]al          

,in=mation disclos$ by a ph>macy b5efit 
manag]1 an affiliate ( a ph>macy b5efit 
manag]1 a ,,pdp sponsor1 or a ph>macy "u
 ?is subsection t is n o!rwise publicly 
available or available = pur*ase %all n 
be disclos$ by ! ,secret>y or a ,,pdp   
sponsor receiv+ ! in=mation1 except t ! 
,secret>y may disclose ! in=mation = !  
foll[+ purposes3 7i7 ,z ! ,secret>y     
det]m9es necess>y to c>ry out ?is "p4   
7ii7 ,to p]mit ! ,comptroll] ,g5]al to  
review ! in=mation provid$4  7iii7 ,to  
p]mit ! ,director ( ! ,congressional    
,budget ,(fice to review ! in=mation    
provid$4  7iv7 ,to p]mit ! ,executive   
,director ( ! ,m$ic>e ,paym5t ,advisory 
,commission to review ! in=mation       
provid$4  7v7 ,to ! ,attorney ,g5]al = !
 purposes ( conduct+ ov]sight & en=cem5t
 "u ?is title4  7vi7 ,to ! ,inspector   
,g5]al ( ! ,dep>tm5t ( ,heal? & ,human  
,s]vices 9 accordance ) its au?orities  
"u ! ,inspector ,g5]al ,act ( #aigh     
7section #djf ( title #e1 ,unit$ ,/ates 
,code71 & o!r applicable /atutes4  7,b7 

,re/riction on use ( in=mation ,!       
,secret>y1 ! ,comptroll] ,g5]al1 !      
,director ( ! ,congressional ,budget    
,(fice1 & ! ,executive ,director ( !    
,m$ic>e ,paym5t ,advisory ,commission   
%all n report on or disclose in=mation  
disclos$ pursuant to subp>agraph 7,a7 to
 ! public 9 a mann] t w\ld id5tify-- 7i7
 a specific ph>macy b5efit manag]1      
affiliate1 ph>macy1 manufactur]1        
:olesal]1 ,,pdp sponsor1 or plan2 or    
7ii7 contract prices1 rebates1 disc\nts1
 or o!r remun]ation = specific drugs 9 a
 mann] t may all[ ! id5tification (     
specific contract+ p>ties or ( su*      
specific drugs4  7#g7 ,def9itions ,=    
purposes ( ?is subsection3 7,a7         
,affiliate ,! t]m affiliate means1 )    
respect to any ph>macy b5efit manag] or 
,,pdp sponsor1 any entity t1 directly or
 indirectly-- 7i7 owns or is own$ by1   
controls or is controll$ by1 or is      
o!rwise relat$ 9 any own]%ip /ructure to
 su* ph>macy b5efit manag] or ,,pdp     
sponsor2 or  7ii7 acts z a contractor1  

pr9cipal1 or ag5t to su* ph>macy b5efit 
manag] or ,,pdp sponsor1 ins(> z su*    
contractor1 pr9cipal1 or ag5t p]=ms any 
( ! functions describ$ "u subp>agraph   
7,c74  7,b7 ,bona fide s]vice fee ,! t]m
 bona fide s]vice fee means a fee t is  
reflective ( ! fair m>ket value 7z      
specifi$ by ! ,secret>y1 ?r\gh notice & 
comm5t rulemak+7 = a bona fide1 itemiz$ 
s]vice actually p]=m$ on behalf ( an    
entity1 t ! entity w\ld o!rwise p]=m 7or
 contract =7 9 ! abs5ce ( ! s]vice      
arrangem5t & t is n pass$ on 9 :ole or 9
 "p to a cli5t or cu/om]1 :e!r or n !   
entity takes title to ! drug4 ,su* fee  
mu/ be a flat doll> am\nt & %all n be   
directly or indirectly bas$ on1 or      
cont+5t ^u-- 7i7 drug price1 su* z      
:olesale acquisition co/ or drug b5*m>k 
price 7su* z av]age :olesale price72    
7ii7 ! am\nt ( disc\nts1 rebates1 fees1 
or o!r direct or indirect remun]ation ) 
respect to cov]$ "p ,d drugs disp5s$ to 
enrollees 9 a prescription drug plan1   
except z p]mitt$ pursuant to p>agraph   

7#a77;,a77ii72  7iii7 cov]age or =mul>y 
placem5t decisions or ! volume or value 
( any ref]rals or bus9ess g5]at$ betwe5 
! p>ties to ! arrangem5t2 or  7iv7 any  
o!r am\nts or me?odologies prohibit$ by 
! ,secret>y4  7,c7 ,ph>macy b5efit      
manag] ,! t]m ph>macy b5efit manag]     
means any p]son or entity t1 ei!r       
directly or ?r\gh an int]m$i>y1 acts z a
 price negotiator or gr\p pur*as] on    
behalf ( a ,,pdp sponsor or prescription
 drug plan1 or manages ! prescription   
drug b5efits provid$ by su* sponsor or  
plan1 includ+ ! process+ & paym5t (     
claims = prescription drugs1 ! p]=mance 
( drug utilization review1 ! process+ ( 
drug prior au?orization reque/s1 !      
adjudication ( appeals or grievances    
relat$ to ! prescription drug b5efit1   
contract+ ) network ph>macies1 controll+
 ! co/ ( cov]$ "p ,d drugs1 or !        
provision ( relat$ s]vices4 ,su* t]m    
includes any p]son or entity t c>ries   
out "o or m ( ! activities describ$ 9 ! 
prec$+ s5t5ce1 irrespective ( :e!r su*  

p]son or entity calls itself a ph>macy  
b5efit manag]4  4  7#b7 ,,ma-,,pd plans 
,section #aheg7;f77#c7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#bg7;f77#c77 is am5d$ by add+ at 
! end ! foll[+ new subp>agraph3  7,f7   
,requirem5ts relat+ to ph>macy b5efit   
manag]s ,= plan ye>s beg9n+ on or aft]  
,janu>y #a1 #bjbi1 section              
#ahfj;,d-#ab7;h74  4  7#c7              
,nonapplication ( ,pap]work ,r$uction   
,act ,*apt] #ce ( title #dd1 ,unit$     
,/ates ,code1 %all n apply to !         
implem5tation ( ?is subsection4  7#d7   
,fund+  7,a7 ,secret>y ,9 addition to   
am\nts o!rwise available1 !re is        
appropriat$ to ! ,c5t]s = ,m$ic>e       
,m$icaid ,s]vices ,program ,managem5t   
,acc\nt1 out ( any money 9 ! ,treasury n
 o!rwise appropriat$1 #aac1jjj1jjj =    
fiscal ye> #bjbf1 to rema9 available    
until exp5d$1 to c>ry out ?is           
subsection4  7,b7 ,,oig ,9 addition to  
am\nts o!rwise available1 !re is        
appropriat$ to ! ,inspector ,g5]al ( !  

,dep>tm5t ( ,heal? & ,human ,s]vices1   
out ( any money 9 ! ,treasury n o!rwise 
appropriat$1 #bj1jjj1jjj = fiscal ye>   
#bjbf1 to rema9 available until exp5d$1 
to c>ry out ?is subsection4  7b7 ,,gao  
,/udy & ,report on ,price-,relat$       
,comp5sation ,across ! ,supply ,*a9     
7#a7 ,/udy ,! ,comptroll] ,g5]al ( !    
,unit$ ,/ates 79 ?is subsection ref]r$  
to z ! ,comptroll] ,g5]al7 %all conduct 
a /udy describ+ ! use ( comp5sation &   
paym5t /ructures relat$ to a            
prescription drug's price )9 ! retail   
prescription drug supply *a9 9 "p ,d (  
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciew-#aja et seq474   
,su* /udy %all summ>ize in=mation f     
,f$]al ag5cies & indu/ry exp]ts1 to !   
ext5t available1 ) respect to ! foll[+3 
7,a7 ,! type1 magnitude1 o!r features   
7su* z ! pric+ b5*m>ks us$71 & preval5ce
 ( comp5sation & paym5t /ructures relat$
 to a prescription drug's price1 su* z  
calculat+ fee am\nts z a p]c5tage ( a   
prescription drug's price1 betwe5       

int]m$i>ies 9 ! prescription drug supply
 *a91 includ+-- 7i7 ph>macy b5efit      
manag]s2  7ii7 ,,pdp sponsors (f]+      
prescription drug plans & ,m$ic>e       
,advantage organizations (f]+ ,,ma-,,pd 
plans2  7iii7 drug :olesal]s2  7iv7     
ph>macies2  7v7 manufactur]s2  7vi7     
ph>macy s]vices adm9i/rative            
organizations2  7vii7 brok]s1 auditors1 
consultants1 & o!r entities t-- 7,i7    
advise ,,pdp sponsors (f]+ prescription 
drug plans & ,m$ic>e ,advantage         
organizations (f]+ ,,ma-,,pd plans      
reg>d+ ph>macy b5efits2 or  7,,ii7      
review ,,pdp sponsor & ,m$ic>e          
,advantage organization contracts )     
ph>macy b5efit manag]s2 &  7viii7 o!r   
s]vice provid]s t contract ) any ( !    
entities describ$ 9 clauses 7i7 ?r\gh   
7vii7 t may use price-relat$ comp5sation
 & paym5t /ructures1 su* z rebate       
aggregators 7or o!r entities t negotiate
 or process price concessions on behalf 
( ph>macy b5efit manag]s1 plan sponsors1
 or ph>macies74  7,b7 ,! prim>y bus9ess 

models & comp5sation /ructures = ea*    
category ( int]m$i>y describ$ 9         
subp>agraph 7,a74  7,c7 ,v>iation 9     
price-relat$ comp5sation /ructures      
betwe5 affiliat$ entities 7su* z        
entities ) common own]%ip1 ei!r full or 
p>tial1 & subsidi>y relation%ips7 &     
unaffiliat$ entities4  7,d7 ,pot5tial   
conflicts ( int]e/ among contract+      
entities relat$ to ! use ( prescription 
drug price-relat$ comp5sation /ructures1
 su* z ! pot5tial = fees or o!r paym5ts 
set z a p]c5tage ( a prescription drug's
 price to advantage =mul>y selection1   
di/ribution1 or pur*as+ ( prescription  
drugs ) high] prices4  7,e7 ,notable    
diff]5ces1 if any1 9 ! use & level (    
price-bas$ comp5sation /ructures ov] "t 
& betwe5 diff]5t m>ket segm5ts1 su* z "u
 "p ,d ( title ,,xviii ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#aciew-#aja et seq47 & ! ,m$icaid       
program "u title ,,xix ( su* ,act 7#db  
,u4,s4,c4 #acif et seq474  7,f7 ,!      
effects ( drug price-relat$ comp5sation 

/ructures & alt]native comp5sation      
/ructures on ,f$]al heal? c>e programs &
 program b5efici>ies1 includ+ ) respect 
to co/-%>+1 premiums1 ,f$]al outlays1   
biosimil> & g5]ic drug adoption &       
utilization1 drug %ortage risks1 & !    
pot5tial = fees set z a p]c5tage ( a    
drug's price to advantage ! =mul>y      
selection1 di/ribution1 or pur*as+ (    
drugs ) high] prices4  7,g7 ,o!r issues 
det]m9$ to be relevant & appropriate by 
! ,comptroll] ,g5]al4  7#b7 ,report ,n  
lat] ?an #b ye>s aft] ! date ( enactm5t 
( ?is section1 ! ,comptroll] ,g5]al %all
 submit to ,congress a report conta9+ ! 
results ( ! /udy conduct$ "u p>agraph   
7#a71 toge!r ) recomm5dations = su*     
legislation & adm9i/rative action z !   
,comptroll] ,g5]al det]m9es appropriate4
  7c7 ,med,p,a,c reports on agreem5ts ) 
ph>macy b5efit manag]s ) respect to     
prescription drug plans & ,,ma-,,pd     
plans  7#a7 ,9 g5]al ,! ,m$ic>e ,paym5t 
,advisory ,commission %all submit to    
,congress ! foll[+ reports3 7,a7        

,initial report ,n lat] ?an ! fir/ ,m>* 
#ae occurr+ aft] ! date t is #b ye>s    
aft] ! date on :i* ! ,secret>y makes !  
data available to ! ,commission1 a      
report reg>d+ agreem5ts ) ph>macy b5efit
 manag]s ) respect to prescription drug 
plans & ,,ma-,,pd plans4 ,su* report    
%all include1 to ! ext5t practicable--  
7i7 a description ( tr5ds & patt]ns1    
includ+ relevant av]ages1 totals1 & o!r 
figures = ! types ( in=mation submitt$2 
7ii7 an analysis ( any diff]5ces 9      
agreem5ts & _! effects on plan enrollee 
out-(-pocket sp5d+ & av]age ph>macy     
reimbursem5t1 & o!r impacts2 &  7iii7   
any recomm5dations ! ,commission        
det]m9es appropriate4  7,b7 ,f9al report
 ,n lat] ?an #b ye>s aft] ! date on :i* 
! ,commission submits ! initial report  
"u subp>agraph 7,a71 a report describ+  
any *anges ) respect to ! in=mation     
describ$ 9 subp>agraph 7,a7 ov] "t1     
toge!r ) any recomm5dations !           
,commission det]m9es appropriate4  7#b7 
,fund+ ,9 addition to am\nts o!rwise    

available1 !re is appropriat$ to !      
,m$ic>e ,paym5t ,advisory ,commission1  
out ( any money 9 ! ,treasury n o!rwise 
appropriat$1 #a1jjj1jjj = fiscal ye>    
#bjbf1 to rema9 available until exp5d$1 
to c>ry out ?is subsection4  #f4 ,full  
rebate pass ?r\gh to plan2 exception =  
innoc5t plan fiduci>ies  7a7 ,9 g5]al   
,section #djh7;b77#b7 ( ! ,employee     
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aajh7;b77#b77 is  
am5d$-- 7#a7 9 subp>agraph 7,b77viii7-- 
7,a7 by r$esignat+ subclauses 7,,ii7    
?r\gh 7,,iv7 z subclauses 7,,iii7 ?r\gh 
7,v71 respectively2  7,b7 9 subclause   
7,i7-- 7i7 by /rik+ subclause 7,,ii7 &  
ins]t+ subclause 7,,iii72 &  7ii7 by    
/rik+ subclauses 7,,ii7 & 7,,iii7 &     
ins]t+ subclauses 7,,iii7 & 7,,iv72 &   
7,c7 by ins]t+ aft] subclause 7,i7 !    
foll[+3  7,,ii7 ,pursuant to subsection 
7a71 subp>agraphs 7,c7 & 7,d7 ( section 
#djf7;a77#a7 %all n apply to a          
responsible plan fiduci>y1 not)/&+ any  
failure to remit requir$ am\nts "u      

subp>agraph 7,c77i71 if ! foll[+        
conditions are met3 7aa7 ,! responsible 
plan fiduci>y did n "k t ! cov]$ s]vice 
provid] fail$ or w\ld fail to make      
requir$ remittances & reasonably believ$
 t ! cov]$ s]vice provid] remitt$ su*   
requir$ am\nts4  7bb7 ,! responsible    
plan fiduci>y1 ^u discov]+ t ! cov]$    
s]vice provid] fail$ to remit ! requir$ 
am\nts1 reque/s 9 writ+ t ! cov]$ s]vice
 provid] remit su* am\nts4  7cc7 ,if !  
cov]$ s]vice provid] fails to comply ) a
 writt5 reque/ describ$ 9 subclause     
7,,iii7 )9 #ij days ( ! reque/1 !       
responsible plan fiduci>y notifies !    
,secret>y ( ! cov]$ s]vice provid]'s    
failure1 9 accordance ) subclauses      
7,,iii7 & 7,,iv74  2 &  7#b7 by add+ at 
! end ! foll[+3  7,c7 7i7 7,i7 ,= plan  
ye>s beg9n+ on or aft] ! date t is #cj  
mon?s aft] ! date ( enactm5t ( ?is      
subp>agraph 7ref]r$ to 9 ?is clause z ! 
effective date71 no contract or         
arrangem5t or r5ewal or ext5sion ( a    
contract or arrangem5t1 ent]$ into on or

 aft] ! effective date1 = s]vices betwe5
 a cov]$ plan & a cov]$ s]vice provid]1 
?r\gh a heal? insurance issu] (f]+ gr\p 
heal? insurance cov]age1 a ?ird p>ty    
adm9i/rator1 an entity provid+ ph>macy  
b5efit managem5t s]vices1 or o!r entity1
 = ph>macy b5efit managem5t s]vices1 is 
reasonable )9 ! mean+ ( ?is p>agraph    
unless su* entity provid+ ph>macy b5efit
 managem5t s]vices-- 7aa7 remits #ajj   
p]c5t ( rebates1 fees1 alt]native       
disc\nts1 & o!r remun]ation receiv$ f   
any applicable entity t are relat$ to   
utilization ( drugs or drug sp5d+ "u su*
 heal? plan or heal? insurance cov]age1 
to ! gr\p heal? plan or heal? insurance 
issu] (f]+ gr\p heal? insurance cov]age2
 &  7bb7 does n ent] into any contract =
 ph>macy b5efit managem5t s]vices on    
behalf ( su* a plan or cov]age1 ) an    
applicable entity unless #ajj p]c5t (   
rebates1 fees1 alt]native disc\nts1 &   
o!r remun]ation receiv$ "u su* contract 
t are relat$ to ! utilization ( drugs or
 drug sp5d+ "u su* gr\p heal? plan or   

heal? insurance cov]age are remitt$ to !
 gr\p heal? plan or heal? insurance     
issu] by ! entity provid+ ph>macy b5efit
 managem5t s]vices4  7,,ii7 ,no?+ 9     
subclause 7,i7 %all be con/ru$ to affect
 ! t]m ( a contract or arrangem5t1 z 9  
effect on ! effective date 7z describ$ 9
 su* subclause71 except t su* subclause 
%all apply to any r5ewal or ext5sion (  
su* a contract or arrangem5t ent]$ into 
on or aft] su* effective date1 z s      
describ$4  7ii7 ,) respect to su*       
rebates1 fees1 alt]native disc\nts1 &   
o!r remun]ation-- 7,i7 ! rebates1 fees1 
alt]native disc\nts1 & o!r remun]ation  
"u clause 7i77,i7 %all be-- 7aa7        
remitt$-- 7,,aa7 on a qu>t]ly basis1 to 
! gr\p heal? plan or ! gr\p heal?       
insurance issu]1 n lat] ?an #ij days    
aft] ! end ( ea* qu>t]2 or 7,,bb7 9 !   
case ( an und]paym5t 9 a remittance = a 
prior qu>t]1 z soon z practicable1 b n  
lat] ?an #ij days aft] notice ( !       
und]paym5t is fir/ giv52  7bb7 fully    
disclos$ & enum]at$ to ! gr\p heal? plan

 or heal? insurance issu]2 &  7cc7      
return$ to ! cov]$ s]vice provid] =     
ph>macy b5efit managem5t s]vices on     
behalf ( ! gr\p heal? plan if any audit 
by a plan sponsor1 issu] or a ?ird p>ty 
designat$ by a plan sponsor1 indicates t
 ! am\nts receiv$ are incorrect aft] su*
 am\nts h be5 paid to ! gr\p heal? plan 
or heal? insurance issu]2  7,,ii7 !     
,secret>y may e/abli% proc$ures = !     
remittance ( rebates fees1 alt]native   
disc\nts1 & o!r remun]ation "u subclause
 7,i77aa7 & ! disclosure ( rebates1     
fees1 alt]native disc\nts1 & o!r        
remun]ation "u subclause 7,i77bb72 &    
7,,iii7 ! records ( su* rebates1 fees1  
alt]native disc\nts1 & o!r remun]ation  
%all be available = audit by ! plan     
sponsor1 issu]1 or a ?ird p>ty designat$
 by a plan sponsor1 n less ?an once p]  
plan ye>4  7iii7 ,to ensure t an entity 
provid+ ph>macy b5efit managem5t s]vices
 is able to meet ! requirem5ts ( clause 
7ii77,i71 a rebate aggregator 7or o!r   
pur*as+ entity design$ to aggregate     

rebates7 & an applicable gr\p pur*as+   
organization %all remit su* rebates to !
 entity provid+ ph>macy b5efit managem5t
 s]vices n lat] ?an #de days aft] ! end 
( ea* qu>t]4  7iv7 ,a ?ird-p>ty         
adm9i/rator ( a gr\p heal? plan1 a heal?
 insurance issu] (f]+ gr\p heal?        
insurance cov]age1 or a cov]$ s]vice    
provid] = ph>macy b5efit managem5t      
s]vices "u su* heal? plan or heal?      
insurance cov]age %all make rebate      
contracts ) rebate aggregators or drug  
manufactur]s available = audit by su*   
plan sponsor or designat$ ?ird p>ty1    
subject to reasonable re/rictions 7z    
det]m9$ by ! ,secret>y7 on              
confid5tiality to prev5t re-disclosure (
 su* contracts or use ( su* in=mation 9 
audits = purposes unrelat$ to ?is       
section4  7v7 ,audits c>ri$ out "u      
clauses 7ii77,,iii7 & 7iv7 %all be p]=m$
 by an auditor select$ by ! responsible 
plan fiduci>y4 ,paym5t = su* audits %all
 n be made1 :e!r directly or indirectly1
 by ! entity provid+ ph>macy b5efit     

managem5t s]vices4  7vi7 ,no?+ 9 ?is    
subp>agraph %all be con/ru$ to-- 7,i7   
prohibit reasonable paym5ts to entities 
(f]+ ph>macy b5efit managem5t s]vices = 
bona fide s]vices us+ a fee /ructure n  
describ$ 9 ?is subp>agraph1 provid$ t   
su* fees are transp>5t & quantifiable to
 gr\p heal? plans & heal? insurance     
issu]s2  7,,ii7 require a ?ird-p>ty     
adm9i/rator ( a gr\p heal? plan or cov]$
 s]vice provid] = ph>macy b5efit        
managem5t s]vices "u su* heal? plan or  
heal? insurance cov]age to remit bona   
fide s]vice fees to ! gr\p heal? plan2  
7,,iii7 limit ! ability ( a gr\p heal?  
plan or heal? insurance issu] to pass   
?r\gh rebates1 fees1 alt]native         
disc\nts1 & o!r remun]ation to !        
p>ticipant or b5efici>y2 or  7,,iv7     
modify ! requirem5ts = ! creation1      
receipt1 ma9t5ance1 or transmission (   
protect$ heal? in=mation "u ! privacy   
regulations promulgat$ "u ! ,heal?      
,insurance ,portability & ,acc\ntability
 ,act ( #aiif 9 "p #afj & subp>ts ,a &  

,e ( "p #afd ( title #de1 ,code ( ,f$]al
 ,regulations 7or successor             
regulations74  7vii7 ,= purposes ( ?is  
subp>agraph-- 7,i7 ! t]ms applicable    
entity & applicable gr\p pur*as+        
organization h ! mean+s giv5 su* t]ms 9 
section #gbf7;e72  7,,ii7 ! t]ms cov]$  
plan1 cov]$ s]vice provid]1 &           
responsible plan fiduci>y h ! mean+s    
giv5 su* t]ms 9 subp>agraph 7,b72 &     
7,,iii7 ! t]ms gr\p heal? insurance     
cov]age1 heal? insurance cov]age1 &     
heal? insurance issu] h ! mean+s giv5   
su* t]ms 9 section #gcc4  4  7b7 ,rule (
 con/ruction ,subclause 7,,ii77aa7 (    
section #djh7;b77#b77;,b77viii7 ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aajh7;b77#b77;,b77viii771 z am5d$ by   
subsection 7a71 %all n be con/ru$ to    
relieve or limit a responsible plan     
fiduci>y f ! duty to monitor ! practices
 ( any cov]$ s]vice provid] t contracts 
) ! applicable cov]$ plan1 includ+ = !  
purposes ( ensur+ ! reasonabl5ess (     

comp5sation4 ,= purposes ( ?is          
subsection1 ! t]ms cov]$ plan1 cov]$    
s]vice provid]1 & responsible plan      
fiduci>y h ! mean+s giv5 su* t]ms 9     
section #djh7;b77#b77;,b77ii7 ( !       
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aajh7;b77#b77;,b77ii774  7c7           
,cl>ification ( cov]$ s]vice provid]    
7#a7 ,s]vices  7,a7 ,9 g5]al ,section   
#djh7;b77#b77;,b77ii77,i77bb7 ( !       
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aajh7;b77#b77;,b77ii77,i77bb77 is      
am5d$-- 7i7 9 subitem 7,,aa7 by /rik+   
,brok]age s]vices1 & ins]t+ ,s]vices    
7includ+ brok]age s]vices712 &  7ii7 9  
subitem 7,,bb7-- 7,i7 by /rik+          
,consult+1 & ins]t+ ,o!r s]vices12 &    
7,,ii7 by /rik+ relat$ to ! developm5t  
or implem5tation ( plan design & all t  
foll[s ?r\gh ! p]iod at ! end & ins]t+  
includ+ any ( ! foll[+3 plan design1    
insurance or insurance product selection
 7includ+ vision & d5tal71 recordkeep+1 

m$ical managem5t1 b5efits adm9i/ration  
selection 7includ+ vision & d5tal71     
/op-loss insurance1 ph>macy b5efit      
managem5t s]vices1 wellness design &    
managem5t s]vices1 transp>5cy tools1    
gr\p pur*as+ organization agreem5ts &   
s]vices1 p>ticipation 9 & s]vices f     
pref]r$ v5dor panels1 disease managem5t1
 compliance s]vices1 employee assi/ance 
programs1 or ?ird p>ty adm9i/ration     
s]vices1 or consult+ s]vices relat$ to  
any su* s]vices44  7,b7 ,s5se (         
,congress ,x is ! s5se ( ,congress t !  
am5dm5t made by subp>agraph 7,a7        
cl>ifies ! exi/+ requirem5t ( cov]$     
s]vice provid]s ) respect to s]vices    
describ$ 9 section                      
#djh7;b77#b77;,b77ii77,i77bb77,,bb7 ( ! 
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aajh7;b77#b77;,b77ii77,i77bb77,,bb77 t 
7 9 effect s9ce ! application date      
describ$ 9 section #bjb7;e7 ( ! ,no     
,surprises ,act 7,public ,law #aaf-bfj2 
#bi ,u4,s4,c4 #aajh note71 & does n     

impose any additional requirem5t "u     
section #djh7;b77#b77;,b7 ( su* ,act4   
7#b7 ,c]ta9 arrangem5ts = ph>macy b5efit
 managem5t s]vices consid]$ z indirect  
7,a7 ,9 g5]al ,section                  
#djh7;b77#b77;,b77i7 ( ! ,employee      
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4                    
#aajh7;b77#b77;,b77i77 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>agraph or subp>agraph 7,c71 a     
contract or arrangem5t = s]vices betwe5 
a cov]$ plan & an entity provid+ s]vices
 to ! plan1 includ+ a heal? insurance   
issu] provid+ heal? insurance cov]age 9 
connection ) ! cov]$ plan1 9 :i* su*    
entity contracts1 9 connection ) su*    
plan1 ) a s]vice provid] = ph>macy      
b5efit managem5t s]vices1 %all be       
consid]$ an indirect furni%+ ( goods1   
s]vices1 or facilities betwe5 ! cov]$   

plan & ! s]vice provid] = ph>macy b5efit
 managem5t s]vices act+ z ! p>ty 9      
int]e/44  7,b7 ,heal? insurance issu] & 
heal? insurance cov]age def9$ ,section  
#djh7;b77#b77;,b77ii77,i77aa7 ( su* ,act
 7#bi ,u4,s4,c4                         
#aajh7;b77#b77;,b77ii77,i77aa77 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 ,section                        
#djh7;b77#b77;,b77ii77,i77aa7 ( !       
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aajh7;b77#b77;,b77ii77,i77aa77 is am5d$
 by ins]t+ 9 aft] def9$4  #g4 ,qualifi$ 
,ex*ange enrollees eligible to e/abli%  
heal? sav+s acc\nts  7a7 ,9 g5]al       
,section #bbc ( ! ,int]nal ,rev5ue ,code
 ( #aihf is am5d$ by add+ at ! end !    
foll[+ new subsection3  7i7 ,qualifi$   
,ex*ange enrollees eligible ,to e/abli% 
heal? sav+s acc\nts  7#a7 ,9 g5]al ,=   
purposes ( ?is section1 an individual :o

 is a qualifi$ ,ex*ange enrollee = any  
mon? dur+ a taxable ye> %all be treat$ z
 an eligible individual = ea* ( ! mon?s 
9 su* taxable ye> & ea* taxable ye>     
!reaft]4 ,not)/&+ ! previ\s s5t5ce1 any 
individual :o elects to make an advance 
premium paym5t "u section               
#adab7;c77#b77;,c7 ( ! ,pati5t          
,protection & ,af=dable ,c>e ,act )     
respect to any mon? dur+ a taxable ye>  
%all n be treat$ z an eligible          
individual = su* mon? or any o!r mon?   
dur+ su* taxable ye>4  7#b7  ,qualifi$  
,ex*ange enrollee  ,= purposes ( ?is    
subsection1 ! t]m qualifi$ ,ex*ange     
enrollee means1 ) respect to any mon?   
dur+ a taxable ye>1 any individual if1 z
 ( ! #a/ day ( su* mon?1 su* individual 
is enroll$ 9 a qualifi$ heal? plan 9 !  
individual m>ket ?r\gh an ,ex*ange      
e/abli%$ "u ! ,pati5t ,protection &     
,af=dable ,c>e ,act t is--  7,a7 ! l[e/ 
co/ bronze plan available to su*        
individual ?r\gh su* ,ex*ange1 or  7,b7 
9 ! case t1 = any mon? dur+ ! prec$+    

taxable ye>1 su* individual 0 enroll$ 9 
a qualifi$ heal? plan 9 ! individual    
m>ket ?r\gh su* an ,ex*ange 7ref]r$ to 9
 ?is p>agraph z ! previ\s plan71 su* a  
qualifi$ heal? plan = :i* ! mon?ly      
premium is l[] ?an ! mon?ly premium t 0 
9 effect = ! previ\s plan4  7#c7        
,application ( mon?ly limitations =     
contributions  ,9 ! case ( an individual
 :o is treat$ z an eligible individual  
"u p>agraph 7#a71 subsection 7b77#b7    
%all be appli$ z if ea* ref]5ce to high 
d$uctible heal? plan 7 a ref]5ce to a   
qualifi$ heal? plan 9 ! individual m>ket
 t 0 enroll$ 9 ?r\gh an ,ex*ange        
e/abli%$ "u ! ,pati5t ,protection &     
,af=dable ,c>e ,act4  7#d7  ,coord9ation
 ) contributions ( p>tial advance       
premium tax cr$it  ,! limitation :i*    
w\ld 7b = ?is p>agraph7 apply "u        
subsection 7b7 = any taxable ye> to an  
individual :o is treat$ z an eligible   
individual "u p>agraph 7#a7 %all be     
r$uc$ 7b n bel[ z]o7 by ! aggregate     
am\nt contribut$ to heal? sav+s acc\nts 

( su* individual = su* taxable ye> "u   
section #adab7;f7 ( ! ,pati5t           
,protection & ,af=dable ,c>e ,act 7& su*
 am\nt %all n be all[$ z a d$uction "u  
subsection 7a774  7#e7  ,all[+ heal?    
insurance to be pur*as$ f acc\nt  ,9 !  
case ( an individual :o is treat$ z an  
eligible individual "u p>agraph 7#a71   
subsection 7d77#b7 %all be appli$ )\t   
reg>d to subp>agraphs 7,b7 & 7,c7 !re(4 
4  7b7 ,effective date ,! am5dm5t made  
by ?is section %all apply to taxable    
ye>s beg9n+ aft] ,decemb] #ca1 #bjbe4   
#h4 ,option to prepay annual premium2   
option to direct p>tial advance paym5t (
 premium tax cr$it into ,,hsa  7a7      
,option ,to prepay annual premium       
,section #adab7;c77#b7 ( ! ,pati5t      
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #ahjhb7;c77#b77 is am5d$--    
7#a7 9 subp>agraph 7,b77i71 by ins]t+ 1 
&1 9 ! case ( an individual :o elects to
 make an advance premium paym5t "u      
subp>agraph 7,c71 fur!r r$uce su*       
premium by #e be=e ! semicolon2  7#b7 by

 r$esignat+ subp>agraph 7,c71 z add$ by 
section #c7;d71 z subp>agraph 7,d72 &   
7#c7 by ins]t+ aft] subp>agraph 7,b7 !  
foll[+ new subp>agraph3  7,c7           
,individual option to prepay annual     
premium ,beg9n+ ) plan ye>s beg9n+ 9    
#bjbf1 9 ! case ( an individual )       
respect to :om an advance det]m9ation   
has be5 made "u section #adaa t su*     
individual is eligible = a premium tax  
cr$it "u section #cf;,b ( ! ,int]nal    
,rev5ue ,code ( #aihf1 if ! premium     
assi/ance am\nt "u subsection 7b77#b7 ( 
su* section is det]m9$ ) respect to su* 
individual 9 accordance ) subsection    
7b77#c77;,a77iii77,,ii7 ( su* section1  
su* individual may elect to make an     
advance premium paym5t to ! issu] ( !   
qualifi$ heal? plan 9 :i* su* individual
 is enroll$ 9 an am\nt equal to #e      
multipli$ by--  7i7 9 ! case t ! advance
 det]m9ation ( eligibility 0 made dur+ !
 annual op5 enrollm5t p]iod = su* plan  
ye>1 #ab2 or  7ii7 9 ! case t ! advance 
det]m9ation ( eligibility 0 made dur+ an

 op5 enrollm5t p]iod o!r ?an ! annual   
op5 enrollm5t p]iod = su* plan ye>1 !   
numb] ( mon?s rema9+ 9 su* plan ye>4  4 
7b7  ,option ,to direct p>tial advance  
paym5t ( premium tax cr$it into ,,hsa   
,section #adab ( ! ,pati5t ,protection &
 ,af=dable ,c>e ,act 7#db ,u4,s4,c4     
#ahjhb7 is am5d$--  7#a7 9 subsection   
7c77#b7-- 7,a7 9 subp>agraph 7,a71 by   
/rik+ ,! & ins]t+ ,subject to subsection
 7f71 !2 &  7,b7 9 subp>agraph 7,b71 by 
ins]t+ 7includ+ su* a paym5t made 9     
accordance ) subsection 7f77 aft] an    
advance paym5t2 &  7#b7 by add+ at ! end
 ! foll[+ new subsection3  7f7 ,option  
,to direct p>tial advance paym5t (      
premium tax cr$it to ,,hsa  7#a7 ,9     
g5]al ,beg9n+ ) plan ye>s beg9n+ 9      
#bjbf1 at ! election ( an eligible      
enroll$ individual describ$ 9 p>agraph  
7#b71 ! advance paym5t ( ! premium tax  
cr$it all[$ "u section #cf;,b ( !       
,int]nal ,rev5ue ,code ( #aihf %all be  
made z foll[s3  7,a7 ,! ,secret>y ( !   
,treasury %all make advance paym5t ( #ej

 p]c5t ( su* premium tax cr$it to !     
issu] ( a qualifi$ heal? plan on a      
mon?ly basis 7or su* o!r p]iodic basis z
 ! ,secret>y may provide74  7,b7 ,!     
,secret>y ( ! ,treasury %all make       
advance paym5t ( #ej p]c5t ( su* premium
 tax cr$it into a heal? sav+s acc\nt 7z 
def9$ 9 section #bbc7;d7 ( ! ,int]nal   
,rev5ue ,code ( #aihf7 ( su* individual 
7z designat$ by su* individual7 on !    
same basis provid$ = "u subp>agraph     
7,a71 b only to ! ext5t t ! aggregate   
am\nt ( su* paym5ts does n exce$ !      
limitation "u section #bbc7;b7 ( su*    
,code 7det]m9$ )\t reg>d to ?is         
subsection7 :i* is applicable to su*    
individual = ! taxable ye> 9 :i* su*    
paym5ts are made4  7#b7  ,eligible      
enroll$ individual  ,= purposes ( ?is   
subsection1 ! t]m eligible enroll$      
individual means1 ) respect to a plan   
ye> 7/>t+ ) #bjbf71 an individual--     
7,a7 ) respect to :om an advance        
det]m9ation has be5 made "u section     
#adaa t su* individual is eligible = a  

premium tax cr$it "u section #cf;,b ( ! 
,int]nal ,rev5ue ,code ( #aihf2  7,b7 :o
 is1 = ! fir/ mon? ( su* plan ye>1 a    
qualifi$ ,ex*ange enrollee 7z def9$ 9   
section #bbc7;i7 ( ! ,int]nal ,rev5ue   
,code ( #aihf72 &  7,c7 :o does n elect 
to make an advance premium paym5t "u    
subsection 7c77#b77;,c74  4  #i4 ,report
 ,n lat] ?an "o ye> aft] ! date ( !     
enactm5t ( ?is ,act1 ! ,secret>y ( !    
,treasury & ! ,secret>y ( ,heal? &      
,human ,s]vices %all jo9tly submit to   
,congress a report on ! implem5tation ( 
sections #g & #h & any recomm5dations on
 exp&+ accessibility ( heal? sav+s      
acc\nts4