,i  #aai? ,,congress  #a/ ,session  ,h4 
,r4 #fgjc  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,decemb] #ae1 #bjbe   
,mrs4 ,mill]-,meeks introduc$ ! foll[+  
bill2 :i* 0 ref]r$ to ! ,committee on   
,en]gy & ,comm]ce1 & 9 addition to !    
,committees on ,education & ,work=ce1 & 
,ways & ,means1 = a p]iod to be         
subsequ5tly det]m9$ by ! ,speak]1 9 ea* 
case = consid]ation ( su* provisions z  
fall )9 ! jurisdiction ( ! committee    
conc]n$  ,a ,,bill  ,to ensure access to
 af=dable heal? insurance4  #a4 ,%ort   
title ,?is ,act may be cit$ z ! ,l[]    
,heal? ,c>e ,premiums = ,all ,am]icans  
,act4  ,i ,improv+ heal? c>e options =  
work]s  #aja4 ,association heal? plans  
7a7 ,treatm5t ( gr\p or association (   
employ]s ,section #c7e7 ( ! ,employee   
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #ajjb7e77 is am5d$ 
by ins]t+ aft] capacity ! foll[+3       
7includ+1 = ! purpose ( e/abli%+ or     
ma9ta9+ a gr\p heal? plan1 a gr\p or    
association ( employ]s t satisfies !    

requirem5ts ( section #gcf7;a774  7b7   
,rules applicable to gr\p heal? plans   
e/abli%$ & ma9ta9$ by a gr\p or         
association ( employ]s  7#a7 ,9 g5]al   
,"p #g ( subtitle ,b ( title ,i ( !     
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4 #aaha1 et   
seq47 is am5d$ by add+ at ! end !       
foll[+3  #gcf4 ,rules applicable to gr\p
 heal? plans e/abli%$ & ma9ta9$ by a    
gr\p or association ( employ]s  7a7     
,association heal? plans ,a gr\p or     
association ( employ]s may ma9ta9 a gr\p
 heal? plan1 reg>dless ( :e!r ! employ]s
 compos+ su* gr\p or association are 9 !
 same indu/ry1 trade1 or pr(ession1 if  
su* gr\p or association satisfies !     
foll[+ requirem5ts3  7#a7 ,gr\p or      
association requirem5ts ,! gr\p or      
association ( employ]s-- 7,a7 %all--    
7i7 h be5 =m$ & ma9ta9$ 9 good fai? =   
purposes o!r ?an provid+ heal? insurance
 cov]age ?r\gh a gr\p heal? plan2  7ii7 
e/abli% a gov]n+ bo>d or ano!r indicator
 ( =mality z describ$ 9 p>agraph 7#b72 &

  7iii7 h exi/$ = at lea/ #b ye>s prior 
to (f]+ a gr\p heal? plan to ! employees
 ( su* gr\p or association2 &  7iv7 make
 heal? insurance cov]age "u ! gr\p heal?
 plan (f]$ by su* gr\p or association   
available--  7,i7 to at lea/ #ea        
employees2 &  7,,ii7 to all employees ( 
! employ] memb]s1 & any dep5d5ts ( su*  
employees2  7,b7 may only provide heal? 
insurance cov]age ?r\gh ! gr\p heal?    
plan ( ! gr\p or association-- 7i7 to an
 employee ( an employ] memb] ( ! gr\p or
 association or a dep5d5t ( su* an      
employee2 or  7ii7 z necess>y to comply 
) "p #f2  7,c7 may include a heal?      
insurance issu] z an employ] memb]1     
except t ! gr\p or association may n--  
7i7 be a heal? insurance issu]2 or  7ii7
 be controll$ or own$ by a heal?        
insurance issu] 7or a subsidi>y or      
affiliate ( a heal? insurance issu]74   
7,d7 may n condition ! memb]%ip ( an    
employ] 9 ! gr\p or association on any  
heal? /atus-relat$ factor 7z describ$ 9 
section #gjb7;a77#a77 relat+ to any     

employee or dep5d5t ( any employee ( any
 employ] memb]4  7#b7 ,organizational   
requirem5ts  7,a7 ,gov]n+ bo>d or =mal  
organization ( ! gr\p or association    
7i7 ,9 g5]al ,! gr\p or association %all
 h--  7,i7 a =mal organizational        
/ructure ) a gov]n+ bo>d & by-laws2 or  
7,,ii7 ano!r /ructure or indicator (    
=mality4  7ii7 ,requirem5t ,bo?         
/ructures describ$ 9 subclauses 7,i7 &  
7,,ii7 ( clause 7i7 %all comply ) !     
requirem5ts describ$ 9 subp>agraph 7,b74
  7,b7 ,=mal organization /ructure (    
gr\p or association  7i7 ,9 g5]al ,!    
functions & activities ( ! gr\p or      
association %all be controll$ by !      
employ] memb]s 9 sub/ance & 9 fact4     
7ii7 ,control ,! control describ$ 9     
clause 7i7 %all be satisfi$ s long z at 
lea/ #ge p]c5t ( ! positions on ! bo>d  
or o!r =mal organizational /ructure are 
held by employ] memb]s4  7iii7          
,elections ,ea* position ( ! gov]n+ bo>d
 or o!r =mal organizational /ructure    
%all be subject to s*$ul$ elections1 z  

det]m9$ by ! gr\p or association1 & ea* 
employ]-memb] %all be able to ca/ only  
"o vote 9 ea* su* election4  7,c7 ,gr\p 
heal? plan requirem5ts  7i7 ,control ,! 
gr\p heal? plan %all be controll$ 9     
sub/ance & 9 fact by employ] memb]s     
p>ticipat+ 9 ! gr\p heal? plan4  7ii7   
,eligibility v]ification ,a plan        
fiduci>y %all v]ify1 on a regul> basis &
 pursuant to reasonable monitor+        
proc$ures z e/abli%$ by ! plan fiduci>y1
 :e!r an individual is a self-employ$   
individual if su* individual 7or a      
b5efici>y !re(7 p>ticipates 9 ! gr\p    
heal? plan on ! basis t su* individual  
is a self-employ$ individual4  7iii7    
,ineligible self-employ$ individuals    
7,i7 ,9 g5]al ,subject to subclause     
7,,ii7 & except z requir$ "u "p #f1 9 ! 
case t ! plan fiduci>y det]m9es t an    
individual :o p>ticipates 9 ! gr\p heal?
 plan no long] meets ! requirem5ts "u a 
self-employ$ individual dur+ a plan ye>1
 ! gr\p heal? plan %all n make heal?    
insurance cov]age available to su*      

individual = any plan ye> foll[+ ! plan 
ye> 9 :i* su* det]m9ation 0 made4       
7,,ii7 ,rem$ial action ,if1 aft] ! plan 
fiduci>y det]m9es t an individual       
describ$ 9 clause 7i7 is n a            
self-employ$ individual1 ! individual   
furni%es to ! plan fiduci>y evid5ce     
prov+ t su* individual is a self-employ$
 individual1 su* individual %all be     
eligible to p>ticipate 9 ! gr\p heal?   
plan4  7#c7 ,discrim9ation & pre-exi/+  
condition protections ,a gr\p heal? plan
 e/abli%$ & ma9ta9$ by ! gr\p or        
association ( employ]s "u ?is section   
may n-- 7,a7 e/abli% any rule =         
eligibility 7includ+ cont9u$            
eligibility7 ( any individual 7includ+  
an employee ( an employ] memb] or a     
self-employ$ individual1 or a dep5d5t ( 
su* employee or self-employ$ individual7
 to enroll = b5efits "u ! t]ms ( ! plan 
t discrim9ates bas$ on any heal?        
/atus-relat$ factor t relates to su*    
individual 7consi/5t ) ! rules "u       
section #gjb7;a77#a772  7,b7 require an 

individual 7includ+ an employee ( an    
employ] memb] or a self-employ$         
individual1 or a dep5d5t ( su* employee 
or self-employ$ individual71 z a        
condition ( enrollm5t or cont9u$        
enrollm5t "u ! plan1 to pay a premium or
 contribution t is great] ?an ! premium 
or contribution = a simil>ly situat$    
individual enroll$ 9 ! plan bas$ on any 
heal? /atus-relat$ factor t relates to  
su* individual 7consi/5t ) ! rules "u   
section #gjb7;b77#a772 &  7,c7 d5y      
cov]age "u su* plan on ! basis ( a      
pre-exi/+ condition 7consi/5t ) ! rules 
"u section #bgjd ( ! ,public ,heal?     
,s]vice ,act74  7b7 ,premium rates = a  
gr\p or association ( employ]s  7#a7 ,9 
g5]al ,a gr\p heal? plan e/abli%$ &     
ma9ta9$ by a gr\p or association (      
employ]s t meets t requirem5ts ( ?is    
section may1 to ! ext5t n prohibit$ "u  
,/ate law-- 7,a7 e/abli% base premium   
rates =m$ on an actu>ially s\nd1 modifi$
 community rat+ me?odology t consid]s ! 
pool+ ( all plan p>ticipant claims2 &   

7,b7 utilize ! specific risk pr(ile (   
ea* employ] memb] ( su* gr\p or         
association to det]m9e contribution     
rates = ea* su* employ] memb]'s %>e ( a 
premium by actu>ially adju/+ ! e/abli%$ 
base premium rates4  7#b7 ,only self    
employ$ individuals ,9 ! case t a gr\p  
or association is compos$ only (        
self-employ$ individuals1 ! gr\p heal?  
plan e/abli%$ by su* gr\p or association
 %all--  7,a7 treat all su* self-employ$
 individuals z a s+le risk pool2  7,b7  
pool all plan p>ticipant claims2 &  7,c7
 *>ge ea* plan p>ticipant ! same premium
 rate4  7c7 ,treatm5t ( self-,employ$   
individuals ,= purposes ( ?is section1  
an individual :o is a self-employ$      
individual %all be treat$ z--  7#a7 an  
employ] :o may be a memb] ( a gr\p or   
association ( employ]s2  7#b7 an        
employee :o may p>ticipate 9 a gr\p     
heal? plan e/abli%$ & ma9ta9$ by su*    
gr\p or association2 &  7#c7 a          
p>ticipant ( ! gr\p heal? plan 9 :i* !  
individual p>ticipates1 subject to !    

eligibility det]m9ation & monitor+      
requirem5ts set =? 9 subsection         
7a77#b77;,c77i74  7d7 ,det]m9ation (    
employ] or jo9t employ] /atus ,!        
provision ( heal? insurance cov]age by a
 gr\p or association ( employ]s may n be
 con/ru$ z evid5ce = e/abli%+ an employ]
 or jo9t employ] relation%ip "u any     
,f$]al or ,/ate law4  7e7 ,rules (      
con/ruction  7#a7 ,no exemption f ,,phsa
 ,no?+ 9 ?is section %all be con/ru$ to 
exempt a gr\p heal? plan 7z def9$ 9     
section #gcc7;a77#a77 (f]$ ?r\gh a gr\p 
or association ( employ]s f !           
requirem5ts ( ?is "p or f ! provisions (
 "p ,a ( title ,,xxvii ( ! ,public      
,heal? ,s]vice ,act z incorporat$ by    
ref]5ce into ?is ,act ?r\gh section     
#gae4  7#b7 ,prior or future guidance   
,no?+ 9 ?is section may be con/ru$ to   
limit or o!rwise affect ! ability ( a   
gr\p or association ( employ]s f        
e/abli%+ a s+le plan multiple employ]   
welf>e arrangem5t z specifi$ 9 any prior
 or future guidance issu$ by ! ,secret>y

 ( ,labor t provides alt]native pa?ways 
to qualify+ z a gr\p or association (   
employ] = purposes ( section #c7e74  7f7
 ,def9itions ,9 ?is section-- 7#a7      
,employ] memb] ,! t]m employ] memb]     
means--  7,a7 an employ] :o is a memb] (
 su* gr\p or association ( employ]s &   
employs at lea/ #a common law employee2 
or  7,b7 a gr\p made up solely (        
self-employ$ individuals1 )9 :i* all ( !
 self-employ$ individual memb]s ( su*   
gr\p or association are aggregat$ toge!r
 z a s+le employ] memb] gr\p1 provid$ t 
su* gr\p includes at lea/ #bj           
self-employ$ individual memb]s4  7#b7   
,self-employ$ individual ,! t]m         
self-employ$ individual means an        
individual :o-- 7,a7 does n h any common
 law employees2  7,b7 has a bona fide   
own]%ip "r 9 a trade or bus9ess1        
reg>dless ( :e!r su* trade or bus9ess is
 incorporat$ or un9corporat$2  7,c7 e>ns
 a wage 7z def9$ 9 section #caba7;a7 ( !
 ,int]nal ,rev5ue ,code ( #aihf7 or     
self-employm5t income 7z def9$ 9 section

 #adjb7;b7 ( su* ,code7 f su* trade or  
bus9ess2 &  7,d7 works at lea/ #aj h\rs 
a week1 or #dj h\rs p] mon?1 provid+    
p]sonal s]vices to su* trade or bus9ess4
  4  7#b7 ,cl]ical am5dm5t ,! table (   
cont5ts is am5d$ by ins]t+ aft] ! item  
relat+ to section #gcd ! foll[+3  #gce4 
,/&>diz$ report+ =mat4 #gcf4 ,rules     
applicable to gr\p heal? plans e/abli%$ 
& ma9ta9$ by a gr\p or association (    
employ]s4  4  #ajb4 ,c]ta9 m$ical       
/op-loss insurance obta9$ by c]ta9 plan 
sponsors ( gr\p heal? plans n includ$ "u
 ! def9ition ( heal? insurance cov]age  
7a7 ,9 g5]al ,section #gcc7;b77#a7 ( !  
,employee ,retirem5t ,income ,security  
,act ( #aigd 7#bi ,u4,s4,c4             
#aaia;b7b77#a77 is am5d$ by add+ at !   
end ! foll[+ s5t5ce3 ,su* t]m %all n    
include a /op-loss policy obta9$ by a   
self-insur$ gr\p heal? plan or a plan   
sponsor ( a gr\p heal? plan t           
self-insures ! heal? risks ( its plan   
p>ticipants to reimburse ! plan or      
sponsor = losses t ! plan or sponsor    

incurs 9 provid+ heal? or m$ical b5efits
 to su* plan p>ticipants 9 excess ( a   
pr$et]m9$ level set =? 9 ! /op-loss     
policy obta9$ by su* plan or sponsor44  
7b7 ,effect on o!r laws ,section        
#ead7;b7 ( ! ,employee ,retirem5t       
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #aadd7;b77 is am5d$ by add+ at
 ! end ! foll[+3  7#aj7 ,! provisions ( 
?is title 7includ+ "p #g relat+ to gr\p 
heal? plans7 %all preempt ,/ate laws    
ins(> z !y may n[ or h]eaft] prev5t an  
employee b5efit plan t is a gr\p heal?  
plan f insur+ aga9/ ! risk ( excess or  
unexpect$ heal? plan claims losses4  4  
#ajc4 ,treatm5t ( heal? reimbursem5t    
arrangem5ts integrat$ ) individual m>ket
 cov]age  7a7 ,9 g5]al  7#a7 ,treatm5t  
,section #ihae7;b7 ( ! ,int]nal ,rev5ue 
,code ( #aihf is am5d$--  7,a7 by /rik+ 
,exception4--,not)/&+ subsection 7a7 &  
ins]t+ ! foll[+3 ,exceptions4--  7#a7   
,self-insur$ gr\p heal? plans ,not)/&+  
subsection 7a7  1 &  7,b7 by add+ at !  
end ! foll[+ new p>agraph3  7#b7 ,cu/om 

heal? option & individual c>e exp5se    
arrangem5ts  7,a7 ,9 g5]al ,= purposes (
 ?is sub*apt]1 a cu/om heal? option &   
individual c>e exp5se arrangem5t %all be
 treat$ z meet+ ! requirem5ts ( section 
#ihjb & sections #bgje1 #bgaa1 #bgac1 & 
#bgae ( title ,,xxvii ( ! ,public ,heal?
 ,s]vice ,act4  7,b7 ,cu/om heal? option
 & individual c>e exp5se arrangem5ts    
def9$ ,= purposes ( ?is section1 ! t]m  
cu/om heal? option & individual c>e     
exp5se arrangem5t means a heal?         
reimbursem5t arrangem5t--  7i7 :i* is an
 employ]-provid$ gr\p heal? plan fund$  
solely by employ] contributions to      
provide paym5ts or reimbursem5ts =      
m$ical c>e subject to a maximum fix$    
doll> am\nt = a p]iod1  7ii7 "u :i* su* 
paym5ts or reimbursem5ts may only be    
made = m$ical c>e provid$ dur+ p]iods   
dur+ :i* ! individual is cov]$--  7,i7  
"u individual heal? insurance cov]age   
7o!r ?an cov]age t consi/s solely (     
except$ b5efits71 or  7,,ii7 "u "p ,a & 
,b ( title ,,xviii ( ! ,social ,security

 ,act or "p ,c ( su* title1  7iii7 :i*  
meets ! nondiscrim9ation requirem5ts (  
subp>agraph 7,c71  7iv7 :i* meets !     
sub/antiation requirem5ts ( subp>agraph 
7,d71 &  7v7 :i* meets ! notice         
requirem5ts ( subp>agraph 7,e74  7,c7   
,nondiscrim9ation  7i7 ,9 g5]al ,an     
arrangem5t meets ! requirem5ts ( ?is    
subp>agraph if an employ] (f]+ su*      
arrangem5t to an employee )9 a specifi$ 
class ( employee--  7,i7 (f]s su*       
arrangem5t to all employees )9 su*      
specifi$ class on ! same t]ms1 &  7,,ii7
 does n (f] any o!r gr\p heal? plan 7o!r
 ?an an acc\nt-bas$ gr\p heal? plan or a
 gr\p heal? plan t consi/s solely (     
except$ b5efits7 to any employees )9 su*
 specifi$ class4  ,9 ! case ( an employ]
 :o (f]s a gr\p heal? plan provid$ ?r\gh
 heal? insurance cov]age 9 ! small gr\p 
m>ket 7t is subject to section #bgja ( !
 ,public ,heal? ,s]vice ,act7 to all    
employees )9 su* specifi$ class1        
subclause 7,,ii7 %all n apply to su*    
gr\p heal? plan4  7ii7 ,specifi$ class (

 employee ,= purposes ( ?is subp>agraph1
 any ( ! foll[+ may be designat$ z a    
specifi$ class ( employee3 7,i7 ,full-"t
 employees4  7,,ii7 ,"p-"t employees4   
7,,iii7 ,sal>i$ employees4  7,,iv7      
,non-sal>i$ employees4  7,v7 ,employees 
^: prim>y site ( employm5t is 9 ! same  
rat+ area4  7,,vi7 ,employees :o are    
includ$ 9 a unit ( employees cov]$ "u a 
collective b>ga9+ agreem5t to :i* !     
employ] is subject 7det]m9$ "u rules    
simil> to ! rules ( section #aje7;h774  
7,,vii7 ,employees :o h n met a gr\p    
heal? plan1 or heal? insurance issu]    
(f]+ gr\p heal? insurance cov]age1 wait+
 p]iod requirem5t t satisfies section   
#bgjh ( ! ,public ,heal? ,s]vice ,act4  
7,,viii7 ,seasonal employees4  7,,ix7   
,employees :o are nonresid5t ali5s & :o 
receive no e>n$ income 7)9 ! mean+ (    
section #iaa7;d77#b77 f ! employ] :i*   
con/itutes income f s\rces )9 ! ,unit$  
,/ates 7)9 ! mean+ ( section            
#hfa7;a77#c774  7,x7 ,"u su* rules z !  
,secret>y may prescribe1 employees :o   

are hir$ = tempor>y placem5t ) an       
unrelat$ p]son t is n ! common law      
employ]4  7,,xi7 ,su* o!r classes (     
employees z ! ,secret>y may designate4  
,an employ] may designate 79 su* mann] z
 is prescrib$ by ! ,secret>y7 two or m (
 ! classes describ$ 9 ! prec$+          
subclauses z ! specifi$ class (         
employees to :i* ! arrangem5t is (f]$ = 
purposes ( apply+ ?is subp>agraph4      
7iii7 ,special rule = new hires ,an     
employ] may designate prospectively s   
mu* ( a specifi$ class ( employees z are
 hir$ aft] a date set by ! employ]4 ,su*
 subclass ( employees %all be treat$ z !
 specifi$ class = purposes ( apply+     
clause 7i74  7iv7 ,rules = det]m9+ type 
( employee ,= purposes = clause 7ii71   
any det]m9ation ( full-"t1 "p-"t1 or    
seasonal employm5t /atus %all be made "u
 rules simil> to ! rules ( section      
#aje7;h7 or #dihj;,h1 :i*ev] ! employ]  
elects = ! plan ye>4 ,su* election %all 
apply ) respect to all employees ( !    
employ] = ! plan ye>4  7v7 ,p]mitt$     

v>iation ,= purposes ( clause 7i77,i71  
an arrangem5t %all n fail to be treat$ z
 provid$ on ! same t]ms )9 a specifi$   
class m]ely because ! maximum doll>     
am\nt ( paym5ts & reimbursem5ts :i* may 
be made "u ! t]ms ( ! arrangem5t = ! ye>
 ) respect to ea* employee )9 su*       
class-- 7,i7 increases z additional     
dep5d5ts ( ! employee are cov]$ "u !    
arrangem5t1 &  7,,ii7 increases )       
respect to a p>ticipant z ! age ( !     
p>ticipant increases1 b n 9 excess ( an 
am\nt equal to #cjj p]c5t ( ! l[e/      
maximum doll> am\nt ) respect to su* a  
p>ticipant det]m9$ )\t reg>d to age4    
7,d7 ,sub/antiation requirem5ts ,an     
arrangem5t meets ! requirem5ts ( ?is    
subp>agraph if ! arrangem5t has         
reasonable proc$ures to sub/antiate--   
7i7 t ! p>ticipant & any dep5d5ts are1  
or w be1 enroll$ 9 cov]age describ$ 9   
subp>agraph 7,b77ii7 z ( ! beg9n+ ( !   
plan ye> ( ! arrangem5t 7or z ( ! beg9n+
 ( cov]age "u ! arrangem5t 9 ! case ( an
 employee :o fir/ becomes eligible to   

p>ticipate 9 ! arrangem5t aft] ! date   
notice is giv5 ) respect to ! plan "u   
subp>agraph 7,e7 7det]m9$ )\t reg>d to  
clause 7iii7 !re(71 &  7ii7 any reque/s 
made = paym5t or reimbursem5t ( m$ical  
c>e "u ! arrangem5t & t ! p>ticipant &  
any dep5d5ts rema9 s enroll$4  7,e7     
,notice  7i7 ,9 g5]al ,except z provid$ 
9 clause 7iii71 an arrangem5t meets !   
requirem5ts ( ?is subp>agraph if1 "u !  
arrangem5t1 ea* employee eligible to    
p>ticipate is1 n lat] ?an #fj days be=e 
! beg9n+ ( ! plan ye>1 giv5 writt5      
notice ( ! employee's rights &          
obligations "u ! arrangem5t :i*-- 7,i7  
is suffici5tly accurate & compreh5sive  
to apprise ! employee ( su* rights &    
obligations1 &  7,,ii7 is writt5 9 a    
mann] calculat$ to be und]/ood by !     
av]age employee eligible to p>ticipate4 
7ii7 ,notice requirem5ts ,su* notice    
%all include su* in=mation z ! ,secret>y
 may by regulation prescribe4  7iii7    
,notice deadl9e = c]ta9 employees ,9 !  
case ( an employee-- 7,i7 :o fir/       

becomes eligible to p>ticipate 9 !      
arrangem5t aft] ! date notice is giv5 ) 
respect to ! plan "u clause 7i7 7det]m9$
 )\t reg>d to ?is clause71 or  7,,ii7 ^:
 employ] is fir/ e/abli%$ few] ?an #abj 
days be=e ! beg9n+ ( ! fir/ plan ye> ( !
 arrangem5t1  ! requirem5ts ( ?is       
subp>agraph %all be treat$ z met if !   
notice requir$ "u clause 7i7 is provid$ 
n lat] ?an ! date ! arrangem5t may take 
effect ) respect to su* employee4  4    
7#b7 ,treatm5t ( curr5t rules relat+ to 
c]ta9 arrangem5ts  7,a7 ,no inf]5ce ,to 
! ext5t n inconsi/5t ) ! am5dm5ts made  
by ?is subsection--  7i7 no inf]5ce %all
 be made f su* am5dm5ts ) respect to !  
rules prescrib$ 9 ! ,f$]al ,regi/] on   
,june #bj1 #bjai1 7#hd ,f$4 ,reg4       
#bhhhh7 relat+ to heal? reimbursem5t    
arrangem5ts & o!r acc\nt-bas$ gr\p heal?
 plans1 &  7ii7 any ref]5ce to cu/om    
heal? option & individual c>e exp5se    
arrangem5ts %all = purposes ( su* rules 
be treat$ z includ+ a ref]5ce to        
individual cov]age heal? reimbursem5t   

arrangem5ts4  7,b7 ,o!r con=m+ ( rules  
,! ,secret>y ( ! ,treasury1 ! ,secret>y 
( ,heal? & ,human ,s]vices1 & !         
,secret>y ( ,labor %all modify su* rules
 z may be necess>y to con=m to !        
am5dm5ts made by ?is subsection4  7#c7  
,p>ticipants 9 ,,*oice arrangem5t       
eligible = pur*ase ( ,ex*ange insurance 
"u cafet]ia plan ,section #abe7;f77#c7 (
 su* ,code is am5d$ by add+ at ! end !  
foll[+ new subp>agraph3  7,c7 ,exception
 = p>ticipants 9 ,,*oice arrangem5t     
,subp>agraph 7,a7 %all n apply 9 ! case 
( an employee p>ticipat+ 9 a cu/om heal?
 option & individual c>e exp5se         
arrangem5t 7)9 ! mean+ ( section        
#ihae7;b77#b77 (f]$ by ! employee's     
employ]4  4  7#d7 ,effective date ,!    
am5dm5ts made by ?is subsection %all    
apply to plan ye>s beg9n+ aft] ,decemb] 
#ca1 #bjbe4  7b7 ,inclusion ( ,,*oice   
arrangem5t p]mitt$ b5efits on ,w-#b     
7#a7 ,9 g5]al ,section #fjea7;a7 ( su*  
,code is am5d$ by /rik+ & at ! end (    
p>agraph 7#ah71 by /rik+ ! p]iod at !   

end ( p>agraph 7#ai7 & ins]t+ 1 &1 & by 
ins]t+ aft] p>agraph 7#ai7 ! foll[+ new 
p>agraph3  7#bj7 ! total am\nt ( p]mitt$
 b5efits = enroll$ individuals "u a     
cu/om heal? option & individual c>e     
exp5se arrangem5t 7z def9$ 9 section    
#ihae7;b77#b77 ) respect to su*         
employee4  4  7#b7 ,effective date ,!   
am5dm5t made by ?is subsection %all     
apply to taxable ye>s beg9n+ aft]       
,decemb] #ca1 #bjbe4  ,,ii ,l[]+ heal?  
c>e premiums = ev]yone  #bja4 ,ov]sight 
( ph>macy b5efit managem5t s]vices  7a7 
,public heal? s]vice act ,title ,,xxvii 
( ! ,public ,heal? ,s]vice ,act 7#db    
,u4,s4,c4 #cjj;gg et seq47 is am5d$--   
7#a7 9 "p ,d 7#db ,u4,s4,c4 #cjj;gg-#aaa
 et seq471 by add+ at ! end ! foll[+ new
 section3  #bgii;,a-#aa4 ,ov]sight (    
entities t provide ph>macy b5efit       
managem5t s]vices  7a7 ,9 g5]al ,= plan 
ye>s beg9n+ on or aft] ! date t is #cj  
mon?s aft] ! date ( enactm5t ( ?is      
section 7ref]r$ to 9 ?is subsection &   
subsection 7b7 z ! effective date71 a   

gr\p heal? plan or a heal? insurance    
issu] (f]+ gr\p heal? insurance cov]age1
 or an entity provid+ ph>macy b5efit    
managem5t s]vices on behalf ( su* a plan
 or issu]1 %all n ent] into a contract1 
includ+ an ext5sion or r5ewal ( a       
contract1 ent]$ into on or aft] !       
effective date1 ) an applicable entity  
unless su* applicable entity agrees to--
  7#a7 n limit or delay ! disclosure (  
in=mation to ! gr\p heal? plan 7includ+ 
su* a plan (f]$ ?r\gh a heal? insurance 
issu]7 9 su* a mann] t prev5ts an entity
 provid+ ph>macy b5efit managem5t       
s]vices on behalf ( a gr\p heal? plan or
 heal? insurance issu] (f]+ gr\p heal?  
insurance cov]age f mak+ ! reports      
describ$ 9 subsection 7b72 &  7#b7      
provide ! entity provid+ ph>macy b5efit 
managem5t s]vices on behalf ( a gr\p    
heal? plan or heal? insurance issu]     
relevant in=mation necess>y to make !   
reports describ$ 9 subsection 7b74  7b7 
,reports  7#a7 ,9 g5]al ,= plan ye>s    
beg9n+ on or aft] ! effective date1 9 ! 

case ( any contract betwe5 a gr\p heal? 
plan or a heal? insurance issu] (f]+    
gr\p heal? insurance cov]age (f]$ 9     
connection ) su* a plan & an entity     
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( su* plan or issu]1 includ+ 
an ext5sion or r5ewal ( su* a contract1 
ent]$ into on or aft] ! effective date1 
! entity provid+ ph>macy b5efit         
managem5t s]vices on behalf ( su* a gr\p
 heal? plan or heal? insurance issu]1 n 
less frequ5tly ?an e #f mon?s 7or1 at ! 
reque/ ( a gr\p heal? plan1 n less      
frequ5tly ?an qu>t]ly1 & "u ! same      
conditions1 t]ms1 & co/ ( ! semiannual  
report "u ?is subsection71 %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 pla9 language1 9 a    
ma*9e-readable =mat1 & z ! ,secret>y may
 det]m9e1 o!r =mats4 ,ea* su* report    
%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 gr\p heal? insurance cov]age    
(f]$ by a heal? insurance issu] 9       
connection ) a gr\p heal? plan dur+ ea* 
report+ p]iod--  7,a7 9 ! case ( a gr\p 
heal? plan t is (f]$ by a specifi$ l>ge 
employ] or t is a specifi$ l>ge plan1 & 
is n (f]$ z heal? insurance cov]age1 or 
9 ! case ( heal? insurance cov]age = :i*
 ! election "u p>agraph 7#c7 is made = !
 applicable report+ p]iod-- 7i7 a li/ ( 
drugs = :i* a claim 0 fil$ &1 ) respect 
to ea* su* drug on su* li/--  7,i7 !    
contract$ comp5sation paid by ! gr\p    
heal? plan or heal? insurance issu] =   
ea* cov]$ drug 7id5tifi$ by ! ,national 
,drug ,code7 to ! entity provid+ ph>macy
 b5efit managem5t s]vices or o!r        
applicable entity on behalf ( ! gr\p    
heal? plan or heal? insurance issu]2    
7,,ii7 ! contract$ comp5sation paid to !
 ph>macy1 by any entity provid+ ph>macy 
b5efit managem5t s]vices or o!r         
applicable entity on behalf ( ! gr\p    

heal? plan or heal? insurance issu]1 =  
ea* cov]$ drug 7id5tifi$ by ! ,national 
,drug ,code72  7,,iii7 = ea* su* claim1 
! diff]5ce betwe5 ! am\nt paid "u       
subclause 7,i7 & ! am\nt paid "u        
subclause 7,,ii72  7,,iv7 ! propriet>y  
"n1 e/abli%$ "n or prop] "n1 & ,national
 ,drug ,code2  7,v7 = ea* claim = ! drug
 7includ+ orig9al prescriptions &       
refills7 & = ea* dosage unit ( ! drug = 
:i* a claim 0 fil$1 ! type ( disp5s+    
*annel us$ to furni% ! drug1 includ+    
retail1 mail ord]1 or specialty ph>macy2
  7,,vi7 ) respect to ea* drug disp5s$1 
= ea* type ( disp5s+ *annel 7includ+    
retail1 mail ord]1 or specialty         
ph>macy7--  7aa7 :e!r su* drug is a br& 
"n drug or a g5]ic drug1 &-- 7,,aa7 9 ! 
case ( a br& "n drug1 ! :olesale        
acquisition co/1 li/$ 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$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7
 p>ticipants & b5efici>ies = :om a claim
 = su* drug 0 fil$ ?r\gh ! applicable   
disp5s+ *annel2 7,,cc7 dosage units &   
dosage units p] fill ( su* drug2 &      
7,,dd7 days supply ( su* drug p] fill2  
7,,vii7 ! 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] rebates1 fees1 alt]native disc\nts1
 or o!r remun]ation receiv$ f applicable
 entities2  7,,viii7 ! total am\nt (    
out-(-pocket sp5d+ by p>ticipants &     
b5efici>ies on su* drug1 includ+ sp5d+  
?r\gh copaym5ts1 co9surance1 &          
d$uctibles1 b n includ+ any am\nts sp5t 
by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan or cov]age1 or = :i* no 
claim is submitt$ "u ! plan or cov]age2 
7,,ix7 ! total net sp5d+ on ! drug2     
7,x7 ! total am\nt receiv$1 or expect$  
to be receiv$1 by ! plan or issu] f any 
applicable entity 9 rebates1 fees1      

alt]native disc\nts1 or o!r remun]ation2
  7,,xi7 ! total am\nt receiv$1 or      
expect$ to be receiv$1 by ! entity      
provid+ ph>macy b5efit managem5t        
s]vices1 f applicable entities1 9       
rebates1 fees1 alt]native disc\nts1 or  
o!r remun]ation f su* entities-- 7aa7 = 
claims incurr$ dur+ ! report+ p]iod2 &  
7bb7 t is relat$ to utilization ( su*   
drug or sp5d+ on su* drug2 &  7,,xii7 to
 ! ext5t feasible1 in=mation on ! total 
am\nt ( remun]ation = su* drug1 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/]+ copaym5t assi/ance on behalf ( 
su* drug manufactur]71 to ! p>ticipants 
& b5efici>ies enroll$ 9 su* plan or     
cov]age2  7ii7 a li/ ( ea* !rapeutic    
class 7z def9$ by ! ,secret>y7 = :i* a  
claim 0 fil$ "u ! gr\p heal? plan or    
heal? insurance cov]age dur+ ! report+  
p]iod1 &1 ) respect to ea* su* !rapeutic
 class-- 7,i7 ! total gross sp5d+ on    
drugs 9 su* class be=e rebates1 price   

concessions1 alt]native disc\nts1 or o!r
 remun]ation f applicable entities2     
7,,ii7 ! net sp5d+ 9 su* class aft] su* 
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f          
applicable entities2  7,,iii7 ! total   
am\nt receiv$1 or expect$ to be receiv$1
 by ! entity provid+ ph>macy b5efit     
managem5t s]vices1 f applicable         
entities1 9 rebates1 fees1 alt]native   
disc\nts1 or o!r remun]ation f su*      
entities--  7aa7 = claims incurr$ dur+ !
 report+ p]iod2 &  7bb7 t is relat$ to  
utilization ( drugs or drug sp5d+2      
7,,iv7 ! av]age net sp5d+ p] #cj-;day   
supply & p] #ij-;day supply by ! plan or
 by ! issu] ) respect to su* cov]age &  
its p>ticipants & b5efici>ies1 among all
 drugs )9 ! !rapeutic class = :i* a     
claim 0 fil$ dur+ ! report+ p]iod2  7,v7
 ! numb] ( p>ticipants & b5efici>ies :o 
fill$ a prescription = a drug 9 su*     
class1 includ+ ! ,national ,drug ,code =
 ea* su* drug2  7,,vi7 if applicable1 a 
description ( ! =mul>y ti]s &           

utilization me*anisms 7su* z prior      
au?orization or /ep !rapy7 employ$ =    
drugs 9 t class2 &  7,,vii7 ! total     
out-(-pocket sp5d+ "u ! plan or cov]age 
by p>ticipants & b5efici>ies1 includ+   
sp5d+ ?r\gh copaym5ts1 co9surance1 &    
d$uctibles1 b n includ+ any am\nts sp5t 
by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan or cov]age or = :i* no  
claim is submitt$ "u ! plan or cov]age2 
7iii7 ) respect to any drug = :i* gross 
sp5d+ "u ! gr\p heal? plan or heal?     
insurance cov]age exce$$ #aj1jjj dur+ ! 
report+ p]iod or1 9 ! case t gross sp5d+
 "u ! gr\p heal? plan or cov]age exce$$ 
#aj1jjj dur+ ! report+ p]iod ) respect  
to few] ?an #ej drugs1 ) respect to !   
#ej prescription drugs ) ! highe/ sp5d+ 
dur+ ! report+ p]iod-- 7,i7 a li/ ( all 
o!r drugs 9 ! same !rapeutic class z su*
 drug2  7,,ii7 if applicable1 !         
rationale = ! =mul>y placem5t ( su* drug
 9 t !rapeutic category or class1       
select$ f a li/ ( /&>d rationales       
e/abli%$ by ! ,secret>y1 9 consultation 

) /akehold]s2 &  7,,iii7 any *ange 9    
=mul>y placem5t comp>$ to ! prior plan  
ye>2 &  7iv7 9 ! case t su* plan or     
issu] 7or an entity provid+ ph>macy     
b5efit managem5t s]vices on behalf ( su*
 plan or issu]7 has an affiliat$ ph>macy
 or ph>macy "u common own]%ip1 includ+  
m&atory mail & specialty home deliv]y   
programs1 retail & mail auto-refill     
programs1 & co/-%>+ assi/ance inc5tives 
fund$ by an entity provid+ ph>macy      
b5efit s]vices-- 7,i7 an explanation (  
any b5efit design p>amet]s t enc\rage or
 require p>ticipants & b5efici>ies 9 !  
plan or cov]age to fill prescriptions at
 mail ord]1 specialty1 or retail        
ph>macies2  7,,ii7 ! p]c5tage ( total   
prescriptions disp5s$ by su* ph>macies  
to p>ticipants or b5efici>ies 9 su* plan
 or cov]age2 &  7,,iii7 a li/ ( all     
drugs disp5s$ by su* ph>macies to       
p>ticipants or b5efici>ies 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>ticipants &           
b5efici>ies2  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>ticipants &  
b5efici>ies1 :5 ! same drug is disp5s$  
by o!r ph>macies t are n affiliat$ ) or 
"u common own]%ip ) ! entity & t are    
includ$ 9 ! ph>macy network ( su* plan  
or cov]age2  7cc7 ! l[e/ co/ p] dosage  
unit1 p] #cj-;day supply & p] #ij-;day  
supply1 = ea* su* drug1 includ+ am\nts  
*>g$ to ! plan or cov]age & to          
p>ticipants & b5efici>ies1 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 ) respect to any 
gr\p heal? plan1 includ+ gr\p heal?     
insurance cov]age (f]$ 9 connection )   
su* a plan1 reg>dless ( :e!r ! plan or  

cov]age is (f]$ by a specifi$ l>ge      
employ] or :e!r x is a specifi$ l>ge    
plan-- 7i7 a summ>y docum5t = ! gr\p    
heal? plan t includes su* in=mation     
describ$ 9 clauses 7i7 ?r\gh 7iv7 (     
subp>agraph 7,a71 z specifi$ by !       
,secret>y ?r\gh guidance1 program       
in/ruction1 or o!rwise 7) no requirem5t 
( notice & comm5t rulemak+71 t !        
,secret>y det]m9es useful to gr\p heal? 
plans = purposes ( select+ ph>macy      
b5efit managem5t s]vices1 su* z an      
e/imat$ net price to gr\p heal? plan &  
p>ticipant or b5efici>y1 a co/ p] claim1
 ! fee /ructure or reimbursem5t model1 &
 e/imat$ co/ p] p>ticipant or b5efici>y2
  7ii7 a summ>y docum5t = plans & issu]s
 to provide to p>ticipants &            
b5efici>ies1 :i* %all be made available 
to p>ticipants or b5efici>ies ^u reque/ 
to _! gr\p heal? plan 7includ+ 9 ! case 
( gr\p heal? insurance cov]age (f]$ 9   
connection ) su* a plan71 t-- 7,i7      
conta9s su* in=mation describ$ 9 clauses
 7iii71 7iv71 7v71 & 7vi71 z applicable1

 z specifi$ by ! ,secret>y ?r\gh        
guidance1 program in/ruction1 or o!rwise
 7) no requirem5t ( notice & comm5t     
rulemak+7 t ! ,secret>y det]m9es useful 
to p>ticipants or b5efici>ies 9 bett]   
und]/&+ ! plan or cov]age or b5efits "u 
su* plan or cov]age2  7,,ii7 conta9s    
only aggregate in=mation2 &  7,,iii7    
/ates t p>ticipants & b5efici>ies may   
reque/ specific1 claims-level in=mation 
requir$ to be furni%$ "u subsection 7c7 
f ! gr\p heal? plan or heal? insurance  
issu]2  7iii7 ) respect to drugs cov]$  
by su* plan or cov]age dur+ su* report+ 
p]iod-- 7,i7 ! total net sp5d+ by ! plan
 or cov]age = all su* drugs2  7,,ii7 !  
total am\nt receiv$1 or expect$ to be   
receiv$1 by ! plan or issu] f any       
applicable entity 9 rebates1 fees1      
alt]native disc\nts1 or o!r remun]ation2
 &  7,,iii7 to ! ext5t feasible1        
in=mation on ! total am\nt ( remun]ation
 = su* drugs1 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/]+ copaym5t
 assi/ance on behalf ( su* drug         
manufactur]7 to p>ticipants &           
b5efici>ies2  7iv7 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]age firms1      
brok]s1 consultants1 advisors1 or any   
o!r individual or firm1 =-- 7,i7 !      
ref]ral ( ! gr\p heal? plan's or heal?  
insurance issu]'s bus9ess to an entity  
provid+ ph>macy b5efit managem5t        
s]vices1 includ+ ! id5tity ( ! recipi5t 
( su* am\nts2  7,,ii7 consid]ation ( !  
entity provid+ ph>macy b5efit managem5t 
s]vices by ! gr\p heal? plan or heal?   
insurance issu]2 or  7,,iii7 ! ret5tion 
( ! entity by ! gr\p heal? plan or heal?
 insurance issu]2  7v7 an explanation ( 
any b5efit design p>amet]s t enc\rage or
 require p>ticipants & b5efici>ies 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 &  7vi7 
total gross sp5d+ on all drugs "u ! plan
 or cov]age dur+ ! report+ p]iod4  7#c7 
,opt-9 = gr\p heal? insurance cov]age   
(f]$ by a specifi$ l>ge employ] or t is 
a specifi$ l>ge plan ,9 ! case ( gr\p   
heal? insurance cov]age (f]$ 9          
connection ) a gr\p heal? plan t is (f]$
 by a specifi$ l>ge employ] or is a     
specifi$ l>ge plan1 su* gr\p heal? plan 
may1 on an annual basis1 = plan ye>s    
beg9n+ on or aft] ! date t is #cj mon?s 
aft] ! date ( enactm5t ( ?is section1   
elect to require an entity provid+      
ph>macy b5efit managem5t s]vices on     
behalf ( ! heal? insurance issu] to     
submit to su* gr\p heal? plan a report t
 includes all ( ! in=mation describ$ 9  

p>agraph 7#b77;,a71 9 addition to !     
in=mation describ$ 9 p>agraph 7#b77;,b74
  7#d7 ,privacy requirem5ts  7,a7 ,9    
g5]al ,an entity provid+ ph>macy b5efit 
managem5t s]vices on behalf ( a gr\p    
heal? plan or a heal? insurance issu]   
(f]+ gr\p heal? insurance cov]age %all  
report in=mation "u p>agraph 7#a7 9 a   
mann] consi/5t ) ! privacy regulations  
promulgat$ "u section #acdjb7;a7 ( !    
,heal? ,in=mation ,te*nology = ,economic
 & ,cl9ical ,heal? ,act & consi/5t ) !  
privacy regulations promulgat$ "u !     
,heal? ,insurance ,portability &        
,acc\ntability ,act ( #aiif 9 "p #afj & 
subp>ts ,a & ,e ( "p #afd ( title #de1  
,code ( ,f$]al ,regulations 7or         
successor regulations7 7ref]r$ to 9 ?is 
p>agraph z ! ,,hipaa privacy            
regulations7 & %all re/rict ! use &     
disclosure ( su* in=mation accord+ to   
su* privacy regulations & su* ,,hipaa   
privacy regulations4  7,b7 ,additional  
requirem5ts  7i7 ,9 g5]al ,an entity    
provid+ ph>macy b5efit 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$]al ,regulations 7or    
successor regulations74  7ii7           
,re/rictions ,9 c>ry+ out ?is           
subsection1 a gr\p heal? plan %all      
comply ) section #afd4ejd7;f7 ( title   
#de1 ,code ( ,f$]al ,regulations 7or a  
successor regulation71 & a plan sponsor 
%all act 9 accordance ) ! t]ms ( !      
agreem5t describ$ 9 su* section4  7,c7  
,rule ( con/ruction  7i7 ,no?+ 9 ?is    
section %all be con/ru$ to modify !     
requirem5ts = ! creation1 receipt1      
ma9t5ance1 or transmission ( protect$   
heal? in=mation "u ! ,,hipaa privacy    
regulations4  7ii7 ,no?+ 9 ?is section  
%all be con/ru$ to affect ! application 
( any ,f$]al or ,/ate privacy or civil  
rights law1 includ+ ! ,,hipaa privacy   
regulations1 ! ,g5etic ,in=mation       

,nondiscrim9ation ,act ( #bjjh 7,public 
,law #aaj-bcc7 7includ+ ! am5dm5ts made 
by su* ,act71 ! ,am]icans )             
,disabilities ,act ( #aiij 7#db         
,u4,s4,c4 #abaja et seq471 section #ejd 
( ! ,rehabilitation ,act ( #aigc 7#bi   
,u4,s4,c4 #gid71 section #aeeg ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi 
( ! ,civil ,rights ,act ( #aifd 7#db    
,u4,s4,c4 #bjjj;d71 & title ,,vii ( !   
,civil ,rights ,act ( #aifd 7#db        
,u4,s4,c4 #bjjj;e74  7,d7 ,writt5 notice
 ,ea* plan ye>1 gr\p heal? plans1       
includ+ ) respect to gr\p heal?         
insurance cov]age (f]$ 9 connection ) a 
gr\p heal? plan1 %all provide to ea*    
p>ticipant or b5efici>y writt5 notice   
in=m+ ! p>ticipant or b5efici>y ( !     
requirem5t = entities provid+ ph>macy   
b5efit managem5t s]vices on behalf ( !  
gr\p heal? plan or heal? insurance issu]
 (f]+ gr\p heal? insurance cov]age to   
submit reports to gr\p heal? plans "u   
p>agraph 7#a71 z applicable1 :i* may    

include incorporat+ su* notification 9  
plan docum5ts provid$ to ! p>ticipant or
 b5efici>y1 or provid+ individual       
notification4  7,e7 ,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 regulations4  7,f7 ,cl>ification
 reg>d+ public disclosure ( in=mation   
,no?+ 9 ?is section %all prev5t an      
entity provid+ ph>macy b5efit managem5t 
s]vices on behalf ( a gr\p heal? plan or
 heal? insurance issu] (f]+ gr\p heal?  
insurance 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-- 7i7 re/rict          
disclosure ( su* report to ! ,dep>tm5t (
 ,heal? & ,human ,s]vices1 ! ,dep>tm5t (

 ,labor1 or ! ,dep>tm5t ( ! ,treasury2  
or  7ii7 prev5t disclosure = ! purposes 
( subsection 7c71 or any o!r public     
disclosure requirem5t "u ?is section4   
7,g7 ,limit$ =m ( report ,! ,secret>y   
%all def9e ?r\gh rulemak+ a limit$ =m ( 
! report "u p>agraph 7#a7 requir$ )     
respect to any gr\p heal? plan e/abli%$ 
by a plan sponsor t is1 or is affiliat$ 
)1 a drug manufactur]1 drug :olesal]1 or
 o!r direct p>ticipant 9 ! drug supply  
*a91 9 ord] to prev5t anti-competitive  
behavior4  7#e7 ,/&>d =mat & regulations
  7,a7 ,9 g5]al ,n lat] ?an #ah mon?s   
aft] ! date ( enactm5t ( ?is section1 ! 
,secret>y %all specify ?r\gh rulemak+ a 
/&>d =mat = entities provid+ ph>macy    
b5efit managem5t s]vices on behalf (    
gr\p heal? plans & heal? insurance      
issu]s (f]+ gr\p heal? insurance        
cov]age1 to submit reports requir$ "u   
p>agraph 7#a74  7,b7 ,additional        
regulations ,n lat] ?an #ah mon?s aft] !
 date ( enactm5t ( ?is section1 !       
,secret>y %all1 ?r\gh rulemak+1         

promulgate any o!r f9al regulations     
necess>y to implem5t ! requirem5ts ( ?is
 section4 ,9 promulgat+ su* regulations1
 ! ,secret>y %all1 to ! ext5t           
practicable1 align ! report+ requirem5ts
 "u ?is section ) ! report+ requirem5ts 
"u section #bgii;,a-#aj4  7c7           
,requirem5t ,to provide in=mation to    
p>ticipants or b5efici>ies ,a gr\p heal?
 plan1 includ+ ) respect to gr\p heal?  
insurance cov]age (f]$ 9 connection ) a 
gr\p heal? plan1 ^u reque/ ( a          
p>ticipant or b5efici>y1 %all provide to
 su* p>ticipant or b5efici>y-- 7#a7 !   
summ>y docum5t describ$ 9 subsection    
7b77#b77;,b77ii72 &  7#b7 ! in=mation   
describ$ 9 subsection                   
7b77#b77;,a77i77,,iii7 ) respect to a   
claim made by or on behalf ( su*        
p>ticipant or b5efici>y4  7d7 ,en=cem5t 
7#a7 ,9 g5]al ,! ,secret>y %all en=ce   
?is section4 ,! en=cem5t au?ority "u ?is
 subsection %all apply only ) respect to
 gr\p heal? plans 7includ+ gr\p heal?   
insurance cov]age (f]$ 9 connection )   

su* a plan7 to :i* ! requirem5ts (      
subp>ts ,i & ,,ii ( "p ,a & "p ,d apply 
9 accordance ) section #bgbb1 & )       
respect to entities provid+ ph>macy     
b5efit managem5t s]vices on behalf ( su*
 plans & applicable entities provid+    
s]vices on behalf ( su* plans4  7#b7    
,failure to provide in=mation ,a gr\p   
heal? plan1 a heal? insurance issu] (f]+
 gr\p heal? insurance cov]age1 an entity
 provid+ ph>macy b5efit managem5t       
s]vices on behalf ( su* a plan or issu]1
 or an applicable entity provid+ s]vices
 on behalf ( su* a plan or issu] t      
violates subsection 7a72 an entity      
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( su* a plan or issu] t fails
 to provide ! in=mation requir$ "u      
subsection 7b72 or a gr\p heal? plan t  
fails to provide ! in=mation requir$ "u 
subsection 7c71 %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]1 an entity provid+
 ph>macy b5efit managem5t s]vices1 or a 
?ird p>ty adm9i/rator provid+ s]vices on
 behalf ( su* issu] (f]$ by a heal?     
insurance issu] t kn[+ly provides false 
in=mation "u ?is section %all be subject
 to a civil monet>y p5alty 9 an am\nt n 
to exce$ #ajj1jjj = ea* item ( false    
in=mation4 ,su* civil monet>y 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  7e7 ,rule (

 con/ruction ,no?+ 9 ?is section %all be
 con/ru$ to p]mit a heal? insurance     
issu]1 gr\p heal? plan1 entity provid+  
ph>macy b5efit managem5t s]vices on     
behalf ( a gr\p heal? plan or heal?     
insurance issu]1 or o!r entity to       
re/rict disclosure to1 or o!rwise limit 
! access (1 ! ,secret>y to a report     
describ$ 9 subsection 7b77#a7 or        
in=mation relat$ to compliance )        
subsections 7a71 7b71 7c71 or 7d7 by su*
 issu]1 plan1 or entity4  7f7           
,def9itions ,9 ?is section3  7#a7       
,applicable entity ,! t]m applicable    
entity means-- 7,a7 an applicable gr\p  
pur*as+ organization1 drug manufactur]1 
di/ributor1 :olesal]1 rebate aggregator 
7or o!r pur*as+ entity design$ to       
aggregate rebates71 or associat$ ?ird   
p>ty2  7,b7 any subsidi>y1 p>5t1        
affiliate1 or subcontractor ( a gr\p    
heal? plan1 heal? insurance issu]1      
entity t provides ph>macy b5efit        
managem5t s]vices on behalf ( su* a plan
 or issu]1 or any entity describ$ 9     

subp>agraph 7,a72 or  7,c7 su* o!r      
entity z ! ,secret>y may specify ?r\gh  
rulemak+4  7#b7 ,applicable gr\p pur*as+
 organization ,! t]m applicable gr\p    
pur*as+ organization means a gr\p       
pur*as+ organization t is affiliat$ ) or
 "u common own]%ip ) an entity provid+  
ph>macy b5efit managem5t s]vices4  7#c7 
,contract$ comp5sation ,! t]m contract$ 
comp5sation means ! sum ( any +r$i5t co/
 & disp5s+ fee = a drug 7inclusive ( !  
out-(-pocket co/s to ! p>ticipant or    
b5efici>y71 or ano!r analog\s           
comp5sation /ructure t ! ,secret>y may  
specify ?r\gh regulations4  7#d7 ,gross 
sp5d+ ,! t]m gross sp5d+1 ) respect to  
prescription drug b5efits "u a gr\p     
heal? plan or heal? insurance cov]age1  
means ! am\nt sp5t by a gr\p heal? plan 
or heal? insurance issu] on prescription
 drug b5efits1 calculat$ be=e !         
application ( rebates1 fees1 alt]native 
disc\nts1 or o!r remun]ation4  7#e7 ,net
 sp5d+ ,! t]m net sp5d+1 ) respect to   
prescription drug b5efits "u a gr\p     

heal? plan or heal? insurance cov]age1  
means ! am\nt sp5t by a gr\p heal? plan 
or heal? insurance issu] on prescription
 drug b5efits1 calculat$ aft] !         
application ( rebates1 fees1 alt]native 
disc\nts1 or o!r remun]ation4  7#f7     
,plan sponsor ,! t]m plan sponsor has ! 
mean+ giv5 su* t]m 9 section #c7af77;,b7
 ( ! ,employee ,retirem5t ,income       
,security ,act ( #aigd4  7#g7           
,remun]ation ,! t]m remun]ation has !   
mean+ giv5 su* t]m by ! ,secret>y ?r\gh 
rulemak+1 :i* %all be reevaluat$ by !   
,secret>y e #e ye>s4  7#h7 ,specifi$    
l>ge employ] ,! t]m specifi$ l>ge       
employ] means1 9 connection ) a gr\p    
heal? plan 7includ+ gr\p heal? insurance
 cov]age (f]$ 9 connection ) su* a plan7
 e/abli%$ or ma9ta9$ by a s+le employ]1 
) respect to a cal5d> ye> or a plan ye>1
 z applicable1 an employ] :o employ$ an 
av]age ( at lea/ #ajj employees on      
bus9ess days dur+ ! prec$+ cal5d> ye> or
 plan ye> & :o employs at lea/ #a       
employee on ! fir/ day ( ! cal5d> ye> or

 plan ye>4  7#i7 ,specifi$ l>ge plan ,! 
t]m specifi$ l>ge plan means a gr\p     
heal? plan 7includ+ gr\p heal? insurance
 cov]age (f]$ 9 connection ) su* a plan7
 e/abli%$ or ma9ta9$ by a plan sponsor  
describ$ 9 clause 7ii7 or 7iii7 (       
section #c7af77;,b7 ( ! ,employee       
,retirem5t ,income ,security ,act (     
#aigd t _h an av]age ( at lea/ #ajj     
p>ticipants on bus9ess days dur+ !      
prec$+ cal5d> ye> or plan ye>1 z        
applicable4  7#aj7 ,: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 section        
#bgii;,a-#aa7 aft] "p ,d2 &  7ii7 9     
p>agraph 7#b71 by ins]t+ 7o!r ?an       
section #bgii;,a-#aa7 aft] "p ,d2 &     
7,b7 9 subsection 7b7--  7i7 9 p>agraph 
7#a71 by ins]t+ 7o!r ?an section        
#bgii;,a-#aa7 aft] "p ,d2  7ii7 9       

p>agraph 7#b77;,a71 by ins]t+ 7o!r ?an  
section #bgii;,a-#aa7 aft] "p ,d2 &     
7iii7 9 p>agraph 7#b77;,c77ii71 by      
ins]t+ 7o!r ?an section #bgii;,a-#aa7   
aft] "p ,d4  7b7 ,employee retirem5t    
income security act ( #aigd  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$--  7,a7 9 subp>t ,b ( "p 
#g 7#bi ,u4,s4,c4 #aahe et seq471 by    
add+ at ! end ! foll[+3  #gbf4 ,ov]sight
 ( entities t provide ph>macy b5efit    
managem5t s]vices  7a7 ,9 g5]al ,= plan 
ye>s beg9n+ on or aft] ! date t is #cj  
mon?s aft] ! date ( enactm5t ( ?is      
section 7ref]r$ to 9 ?is subsection &   
subsection 7b7 z ! effective date71 a   
gr\p heal? plan or a heal? insurance    
issu] (f]+ gr\p heal? insurance cov]age1
 or an entity provid+ ph>macy b5efit    
managem5t s]vices on behalf ( su* a plan
 or issu]1 %all n ent] into a contract1 
includ+ an ext5sion or r5ewal ( a       
contract1 ent]$ into on or aft] !       

effective date1 ) an applicable entity  
unless su* applicable entity agrees to--
  7#a7 n limit or delay ! disclosure (  
in=mation to ! gr\p heal? plan 7includ+ 
su* a plan (f]$ ?r\gh a heal? insurance 
issu]7 9 su* a mann] t prev5ts an entity
 provid+ ph>macy b5efit managem5t       
s]vices on behalf ( a gr\p heal? plan or
 heal? insurance issu] (f]+ gr\p heal?  
insurance cov]age f mak+ ! reports      
describ$ 9 subsection 7b72 &  7#b7      
provide ! entity provid+ ph>macy b5efit 
managem5t s]vices on behalf ( a gr\p    
heal? plan or heal? insurance issu]     
relevant in=mation necess>y to make !   
reports describ$ 9 subsection 7b74  7b7 
,reports  7#a7 ,9 g5]al ,= plan ye>s    
beg9n+ on or aft] ! effective date1 9 ! 
case ( any contract betwe5 a gr\p heal? 
plan or a heal? insurance issu] (f]+    
gr\p heal? insurance cov]age (f]$ 9     
connection ) su* a plan & an entity     
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( su* plan or issu]1 includ+ 
an ext5sion or r5ewal ( su* a contract1 

ent]$ into on or aft] ! effective date1 
! entity provid+ ph>macy b5efit         
managem5t s]vices on behalf ( su* a gr\p
 heal? plan or heal? insurance issu]1 n 
less frequ5tly ?an e #f mon?s 7or1 at ! 
reque/ ( a gr\p heal? plan1 n less      
frequ5tly ?an qu>t]ly1 & "u ! same      
conditions1 t]ms1 & co/ ( ! semiannual  
report "u ?is subsection71 %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 pla9 language1 9 a    
ma*9e-readable =mat1 & z ! ,secret>y may
 det]m9e1 o!r =mats4 ,ea* su* report    
%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 gr\p heal? insurance cov]age    
(f]$ by a heal? insurance issu] 9       
connection ) a gr\p heal? plan dur+ ea* 
report+ p]iod--  7,a7 9 ! case ( a gr\p 
heal? plan t is (f]$ by a specifi$ l>ge 

employ] or t is a specifi$ l>ge plan1 & 
is n (f]$ z heal? insurance cov]age1 or 
9 ! case ( heal? insurance cov]age = :i*
 ! election "u p>agraph 7#c7 is made = !
 applicable report+ p]iod-- 7i7 a li/ ( 
drugs = :i* a claim 0 fil$ &1 ) respect 
to ea* su* drug on su* li/--  7,i7 !    
contract$ comp5sation paid by ! gr\p    
heal? plan or heal? insurance issu] =   
ea* cov]$ drug 7id5tifi$ by ! ,national 
,drug ,code7 to ! entity provid+ ph>macy
 b5efit managem5t s]vices or o!r        
applicable entity on behalf ( ! gr\p    
heal? plan or heal? insurance issu]2    
7,,ii7 ! contract$ comp5sation paid to !
 ph>macy1 by any entity provid+ ph>macy 
b5efit managem5t s]vices or o!r         
applicable entity on behalf ( ! gr\p    
heal? plan or heal? insurance issu]1 =  
ea* cov]$ drug 7id5tifi$ by ! ,national 
,drug ,code72  7,,iii7 = ea* su* claim1 
! diff]5ce betwe5 ! am\nt paid "u       
subclause 7,i7 & ! am\nt paid "u        
subclause 7,,ii72  7,,iv7 ! propriet>y  
"n1 e/abli%$ "n or prop] "n1 & ,national

 ,drug ,code2  7,v7 = ea* claim = ! drug
 7includ+ orig9al prescriptions &       
refills7 & = ea* dosage unit ( ! drug = 
:i* a claim 0 fil$1 ! type ( disp5s+    
*annel us$ to furni% ! drug1 includ+    
retail1 mail ord]1 or specialty ph>macy2
  7,,vi7 ) respect to ea* drug disp5s$1 
= ea* type ( disp5s+ *annel 7includ+    
retail1 mail ord]1 or specialty         
ph>macy7--  7aa7 :e!r su* drug is a br& 
"n drug or a g5]ic drug1 &-- 7,,aa7 9 ! 
case ( a br& "n drug1 ! :olesale        
acquisition co/1 li/$ 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$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7
 p>ticipants & b5efici>ies = :om a claim
 = su* drug 0 fil$ ?r\gh ! applicable   
disp5s+ *annel2 7,,cc7 dosage units &   
dosage units p] fill ( su* drug2 &      

7,,dd7 days supply ( su* drug p] fill2  
7,,vii7 ! 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] rebates1 fees1 alt]native disc\nts1
 or o!r remun]ation receiv$ f applicable
 entities2  7,,viii7 ! total am\nt (    
out-(-pocket sp5d+ by p>ticipants &     
b5efici>ies on su* drug1 includ+ sp5d+  
?r\gh copaym5ts1 co9surance1 &          
d$uctibles1 b n includ+ any am\nts sp5t 
by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan or cov]age1 or = :i* no 
claim is submitt$ "u ! plan or cov]age2 
7,,ix7 ! total net sp5d+ on ! drug2     
7,x7 ! total am\nt receiv$1 or expect$  
to be receiv$1 by ! plan or issu] f any 
applicable entity 9 rebates1 fees1      
alt]native disc\nts1 or o!r remun]ation2
  7,,xi7 ! total am\nt receiv$1 or      
expect$ to be receiv$1 by ! entity      
provid+ ph>macy b5efit managem5t        
s]vices1 f applicable entities1 9       
rebates1 fees1 alt]native disc\nts1 or  
o!r remun]ation f su* entities-- 7aa7 = 

claims incurr$ dur+ ! report+ p]iod2 &  
7bb7 t is relat$ to utilization ( su*   
drug or sp5d+ on su* drug2 &  7,,xii7 to
 ! ext5t feasible1 in=mation on ! total 
am\nt ( remun]ation = su* drug1 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/]+ copaym5t assi/ance on behalf ( 
su* drug manufactur]71 to ! p>ticipants 
& b5efici>ies enroll$ 9 su* plan or     
cov]age2  7ii7 a li/ ( ea* !rapeutic    
class 7z def9$ by ! ,secret>y7 = :i* a  
claim 0 fil$ "u ! gr\p heal? plan or    
heal? insurance cov]age dur+ ! report+  
p]iod1 &1 ) respect to ea* su* !rapeutic
 class-- 7,i7 ! total gross sp5d+ on    
drugs 9 su* class be=e rebates1 price   
concessions1 alt]native disc\nts1 or o!r
 remun]ation f applicable entities2     
7,,ii7 ! net sp5d+ 9 su* class aft] su* 
rebates1 price concessions1 alt]native  
disc\nts1 or o!r remun]ation f          
applicable entities2  7,,iii7 ! total   
am\nt receiv$1 or expect$ to be receiv$1

 by ! entity provid+ ph>macy b5efit     
managem5t s]vices1 f applicable         
entities1 9 rebates1 fees1 alt]native   
disc\nts1 or o!r remun]ation f su*      
entities--  7aa7 = claims incurr$ dur+ !
 report+ p]iod2 &  7bb7 t is relat$ to  
utilization ( drugs or drug sp5d+2      
7,,iv7 ! av]age net sp5d+ p] #cj-;day   
supply & p] #ij-;day supply by ! plan or
 by ! issu] ) respect to su* cov]age &  
its p>ticipants & b5efici>ies1 among all
 drugs )9 ! !rapeutic class = :i* a     
claim 0 fil$ dur+ ! report+ p]iod2  7,v7
 ! numb] ( p>ticipants & b5efici>ies :o 
fill$ a prescription = a drug 9 su*     
class1 includ+ ! ,national ,drug ,code =
 ea* su* drug2  7,,vi7 if applicable1 a 
description ( ! =mul>y ti]s &           
utilization me*anisms 7su* z prior      
au?orization or /ep !rapy7 employ$ =    
drugs 9 t class2 &  7,,vii7 ! total     
out-(-pocket sp5d+ "u ! plan or cov]age 
by p>ticipants & b5efici>ies1 includ+   
sp5d+ ?r\gh copaym5ts1 co9surance1 &    
d$uctibles1 b n includ+ any am\nts sp5t 

by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan or cov]age or = :i* no  
claim is submitt$ "u ! plan or cov]age2 
7iii7 ) respect to any drug = :i* gross 
sp5d+ "u ! gr\p heal? plan or heal?     
insurance cov]age exce$$ #aj1jjj dur+ ! 
report+ p]iod or1 9 ! case t gross sp5d+
 "u ! gr\p heal? plan or cov]age exce$$ 
#aj1jjj dur+ ! report+ p]iod ) respect  
to few] ?an #ej drugs1 ) respect to !   
#ej prescription drugs ) ! highe/ sp5d+ 
dur+ ! report+ p]iod-- 7,i7 a li/ ( all 
o!r drugs 9 ! same !rapeutic class z su*
 drug2  7,,ii7 if applicable1 !         
rationale = ! =mul>y placem5t ( su* drug
 9 t !rapeutic category or class1       
select$ f a li/ ( /&>d rationales       
e/abli%$ by ! ,secret>y1 9 consultation 
) /akehold]s2 &  7,,iii7 any *ange 9    
=mul>y placem5t comp>$ to ! prior plan  
ye>2 &  7iv7 9 ! case t su* plan or     
issu] 7or an entity provid+ ph>macy     
b5efit managem5t s]vices on behalf ( su*
 plan or issu]7 has an affiliat$ ph>macy
 or ph>macy "u common own]%ip1 includ+  

m&atory mail & specialty home deliv]y   
programs1 retail & mail auto-refill     
programs1 & co/ %>+ assi/ance inc5tives 
fund$ by an entity provid+ ph>macy      
b5efit s]vices-- 7,i7 an explanation (  
any b5efit design p>amet]s t enc\rage or
 require p>ticipants & b5efici>ies 9 !  
plan or cov]age to fill prescriptions at
 mail ord]1 specialty1 or retail        
ph>macies2  7,,ii7 ! p]c5tage ( total   
prescriptions disp5s$ by su* ph>macies  
to p>ticipants or b5efici>ies 9 su* plan
 or cov]age2 &  7,,iii7 a li/ ( all     
drugs disp5s$ by su* ph>macies to       
p>ticipants or b5efici>ies enroll$ 9 su*
 plan or cov]age1 &1 ) respect to ea*   
drug disp5s$--  7aa7 ! am\nt *>g$1 p]   
dosage unit1 p] #cj-;day supply1 or p]  
#ij-;day supply 7z applicable7 to ! plan
 or issu]1 & to p>ticipants &           
b5efici>ies2  7bb7 ! m$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>ticipants &  

b5efici>ies1 :5 ! same drug is disp5s$  
by o!r ph>macies t are n affiliat$ ) or 
"u common own]%ip ) ! entity & t are    
includ$ 9 ! ph>macy network ( su* plan  
or cov]age2  7cc7 ! l[e/ co/ p] dosage  
unit1 p] #cj-;day supply & p] #ij-;day  
supply1 = ea* su* drug1 includ+ am\nts  
*>g$ to ! plan or cov]age & to          
p>ticipants & b5efici>ies1 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 ) respect to any 
gr\p heal? plan1 includ+ gr\p heal?     
insurance cov]age (f]$ 9 connection )   
su* a plan1 reg>dless ( :e!r ! plan or  
cov]age is (f]$ by a specifi$ l>ge      
employ] or :e!r x is a specifi$ l>ge    
plan-- 7i7 a summ>y docum5t = ! gr\p    
heal? plan t includes su* in=mation     
describ$ 9 clauses 7i7 ?r\gh 7iv7 (     
subp>agraph 7,a71 z specifi$ by !       
,secret>y ?r\gh guidance1 program       

in/ruction1 or o!rwise 7) no requirem5t 
( notice & comm5t rulemak+71 t !        
,secret>y det]m9es useful to gr\p heal? 
plans = purposes ( select+ ph>macy      
b5efit managem5t s]vices1 su* z an      
e/imat$ net price to gr\p heal? plan &  
p>ticipant or b5efici>y1 a co/ p] claim1
 ! fee /ructure or reimbursem5t model1 &
 e/imat$ co/ p] p>ticipant or b5efici>y2
  7ii7 a summ>y docum5t = plans & issu]s
 to provide to p>ticipants &            
b5efici>ies1 :i* %all be made available 
to p>ticipants or b5efici>ies ^u reque/ 
to _! gr\p heal? plan 7includ+ 9 ! case 
( gr\p heal? insurance cov]age (f]$ 9   
connection ) su* a plan71 t-- 7,i7      
conta9s su* in=mation describ$ 9 clauses
 7iii71 7iv71 7v71 & 7vi71 z applicable1
 z specifi$ by ! ,secret>y ?r\gh        
guidance1 program in/ruction1 or o!rwise
 7) no requirem5t ( notice & comm5t     
rulemak+7 t ! ,secret>y det]m9es useful 
to p>ticipants or b5efici>ies 9 bett]   
und]/&+ ! plan or cov]age or b5efits "u 
su* plan or cov]age2  7,,ii7 conta9s    

only aggregate in=mation2 &  7,,iii7    
/ates t p>ticipants & b5efici>ies may   
reque/ specific1 claims-level in=mation 
requir$ to be furni%$ "u subsection 7c7 
f ! gr\p heal? plan or heal? insurance  
issu]2  7iii7 ) respect to drugs cov]$  
by su* plan or cov]age dur+ su* report+ 
p]iod-- 7,i7 ! total net sp5d+ by ! plan
 or cov]age = all su* drugs2  7,,ii7 !  
total am\nt receiv$1 or expect$ to be   
receiv$1 by ! plan or issu] f any       
applicable entity 9 rebates1 fees1      
alt]native disc\nts1 or o!r remun]ation2
 &  7,,iii7 to ! ext5t feasible1        
in=mation on ! total am\nt ( remun]ation
 = su* drugs1 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/]+ copaym5t
 assi/ance on behalf ( su* drug         
manufactur]7 to p>ticipants &           
b5efici>ies2  7iv7 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]age firms1 brok]s1 consultants1
 advisors1 or any o!r individual or     
firm1 =-- 7,i7 ! ref]ral ( ! gr\p heal? 
plan's or heal? insurance issu]'s       
bus9ess to an entity provid+ ph>macy    
b5efit managem5t s]vices1 includ+ !     
id5tity ( ! recipi5t ( su* am\nts2      
7,,ii7 consid]ation ( ! entity provid+  
ph>macy b5efit managem5t s]vices by !   
gr\p heal? plan or heal? insurance      
issu]2 or  7,,iii7 ! ret5tion ( ! entity
 by ! gr\p heal? plan or heal? insurance
 issu]2  7v7 an explanation ( any b5efit
 design p>amet]s t enc\rage or require  
p>ticipants & b5efici>ies 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 &  7vi7 total gross sp5d+ on all

 drugs "u ! plan or cov]age dur+ !      
report+ p]iod4  7#c7 ,opt-9 = gr\p heal?
 insurance cov]age (f]$ by a specifi$   
l>ge employ] or t is a specifi$ l>ge    
plan ,9 ! case ( gr\p heal? insurance   
cov]age (f]$ 9 connection ) a gr\p heal?
 plan t is (f]$ by a specifi$ l>ge      
employ] or is a specifi$ l>ge plan1 su* 
gr\p heal? plan may1 on an annual basis1
 = plan ye>s beg9n+ on or aft] ! date t 
is #cj mon?s aft] ! date ( enactm5t (   
?is section1 elect to require an entity 
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( ! heal? insurance issu] to 
submit to su* gr\p heal? plan a report t
 includes all ( ! in=mation describ$ 9  
p>agraph 7#b77;,a71 9 addition to !     
in=mation describ$ 9 p>agraph 7#b77;,b74
  7#d7 ,privacy requirem5ts  7,a7 ,9    
g5]al ,an entity provid+ ph>macy b5efit 
managem5t s]vices on behalf ( a gr\p    
heal? plan or a heal? insurance issu]   
(f]+ gr\p heal? insurance cov]age %all  
report in=mation "u p>agraph 7#a7 9 a   
mann] consi/5t ) ! privacy regulations  

promulgat$ "u section #acdjb7;a7 ( !    
,heal? ,in=mation ,te*nology = ,economic
 & ,cl9ical ,heal? ,act 7#db ,u4,s4,c4  
#agicb7;a77 & consi/5t ) ! privacy      
regulations promulgat$ "u ! ,heal?      
,insurance ,portability & ,acc\ntability
 ,act ( #aiif 9 "p #afj & subp>ts ,a &  
,e ( "p #afd ( title #de1 ,code ( ,f$]al
 ,regulations 7or successor regulations7
 7ref]r$ to 9 ?is p>agraph z ! ,,hipaa  
privacy regulations7 & %all re/rict !   
use & disclosure ( su* in=mation accord+
 to su* privacy regulations & su*       
,,hipaa privacy regulations4  7,b7      
,additional requirem5ts  7i7 ,9 g5]al   
,an entity provid+ ph>macy b5efit       
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 ,9     

c>ry+ out ?is subsection1 a gr\p heal?  
plan %all comply ) section #afd4ejd7;f7 
( title #de1 ,code ( ,f$]al ,regulations
 7or a successor regulation71 & a plan  
sponsor %all act 9 accordance ) ! t]ms (
 ! agreem5t describ$ 9 su* section4     
7,c7 ,rule ( con/ruction  7i7 ,no?+ 9   
?is section %all be con/ru$ to modify ! 
requirem5ts = ! creation1 receipt1      
ma9t5ance1 or transmission ( protect$   
heal? in=mation "u ! ,,hipaa privacy    
regulations4  7ii7 ,no?+ 9 ?is section  
%all be con/ru$ to affect ! application 
( any ,f$]al or ,/ate privacy or civil  
rights law1 includ+ ! ,,hipaa privacy   
regulations1 ! ,g5etic ,in=mation       
,nondiscrim9ation ,act ( #bjjh 7,public 
,law #aaj-bcc7 7includ+ ! am5dm5ts made 
by su* ,act71 ! ,am]icans )             
,disabilities ,act ( #aiij 7#db         
,u4,s4,c4 #abaja et seq471 section #ejd 
( ! ,rehabilitation ,act ( #aigc 7#bi   
,u4,s4,c4 #gid71 section #aeeg ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi 

( ! ,civil ,rights ,act ( #aifd 7#db    
,u4,s4,c4 #bjjj;d71 & title ,,vii ( !   
,civil ,rights ,act ( #aifd 7#db        
,u4,s4,c4 #bjjj;e74  7,d7 ,writt5 notice
 ,ea* plan ye>1 gr\p heal? plans1       
includ+ ) respect to gr\p heal?         
insurance cov]age (f]$ 9 connection ) a 
gr\p heal? plan1 %all provide to ea*    
p>ticipant or b5efici>y writt5 notice   
in=m+ ! p>ticipant or b5efici>y ( !     
requirem5t = entities provid+ ph>macy   
b5efit managem5t s]vices on behalf ( !  
gr\p heal? plan or heal? insurance issu]
 (f]+ gr\p heal? insurance cov]age to   
submit reports to gr\p heal? plans "u   
p>agraph 7#a71 z applicable1 :i* may    
include incorporat+ su* notification 9  
plan docum5ts provid$ to ! p>ticipant or
 b5efici>y1 or provid+ individual       
notification4  7,e7 ,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 regulations4  7,f7 ,cl>ification
 reg>d+ public disclosure ( in=mation   
,no?+ 9 ?is section %all prev5t an      
entity provid+ ph>macy b5efit managem5t 
s]vices on behalf ( a gr\p heal? plan or
 heal? insurance issu] (f]+ gr\p heal?  
insurance 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-- 7i7 re/rict          
disclosure ( su* report to ! ,dep>tm5t (
 ,heal? & ,human ,s]vices1 ! ,dep>tm5t (
 ,labor1 or ! ,dep>tm5t ( ! ,treasury2  
or  7ii7 prev5t disclosure = ! purposes 
( subsection 7c71 or any o!r public     
disclosure requirem5t "u ?is section4   
7,g7 ,limit$ =m ( report ,! ,secret>y   
%all def9e ?r\gh rulemak+ a limit$ =m ( 
! report "u p>agraph 7#a7 requir$ )     
respect to any gr\p heal? plan e/abli%$ 
by a plan sponsor t is1 or is affiliat$ 

)1 a drug manufactur]1 drug :olesal]1 or
 o!r direct p>ticipant 9 ! drug supply  
*a91 9 ord] to prev5t anti-competitive  
behavior4  7#e7 ,/&>d =mat & regulations
  7,a7 ,9 g5]al ,n lat] ?an #ah mon?s   
aft] ! date ( enactm5t ( ?is section1 ! 
,secret>y %all specify ?r\gh rulemak+ a 
/&>d =mat = entities provid+ ph>macy    
b5efit managem5t s]vices on behalf (    
gr\p heal? plans & heal? insurance      
issu]s (f]+ gr\p heal? insurance        
cov]age1 to submit reports requir$ "u   
p>agraph 7#a74  7,b7 ,additional        
regulations ,n lat] ?an #ah mon?s aft] !
 date ( enactm5t ( ?is section1 !       
,secret>y %all1 ?r\gh rulemak+1         
promulgate any o!r f9al regulations     
necess>y to implem5t ! requirem5ts ( ?is
 section4 ,9 promulgat+ su* regulations1
 ! ,secret>y %all1 to ! ext5t           
practicable1 align ! report+ requirem5ts
 "u ?is section ) ! report+ requirem5ts 
"u section #gbe4  7c7 ,requirem5t ,to   
provide in=mation to p>ticipants or     
b5efici>ies ,a gr\p heal? plan1 includ+ 

) respect to gr\p heal? insurance       
cov]age (f]$ 9 connection ) a gr\p heal?
 plan1 ^u reque/ ( a p>ticipant or      
b5efici>y1 %all provide to su*          
p>ticipant or b5efici>y-- 7#a7 ! summ>y 
docum5t describ$ 9 subsection           
7b77#b77;,b77ii72 &  7#b7 ! in=mation   
describ$ 9 subsection                   
7b77#b77;,a77i77,,iii7 ) respect to a   
claim made by or on behalf ( su*        
p>ticipant or b5efici>y4  7d7 ,rule (   
con/ruction ,no?+ 9 ?is section %all be 
con/ru$ to p]mit a heal? insurance      
issu]1 gr\p heal? plan1 entity provid+  
ph>macy b5efit managem5t s]vices on     
behalf ( a gr\p heal? plan or heal?     
insurance issu]1 or o!r entity to       
re/rict disclosure to1 or o!rwise limit 
! access (1 ! ,secret>y to a report     
describ$ 9 subsection 7b77#a7 or        
in=mation relat$ to compliance )        
subsections 7a71 7b71 or 7c7 ( ?is      
section or section #ejb7;c77#ac7 by su* 
issu]1 plan1 or entity4  7e7 ,def9itions
 ,9 ?is section3 7#a7 ,applicable entity

 ,! t]m applicable entity means--  7,a7 
an applicable gr\p pur*as+ organization1
 drug manufactur]1 di/ributor1 :olesal]1
 rebate aggregator 7or o!r pur*as+      
entity design$ to aggregate rebates71 or
 associat$ ?ird p>ty2  7,b7 any         
subsidi>y1 p>5t1 affiliate1 or          
subcontractor ( a gr\p heal? plan1 heal?
 insurance issu]1 entity t provides     
ph>macy b5efit managem5t s]vices on     
behalf ( su* a plan or issu]1 or any    
entity describ$ 9 subp>agraph 7,a72 or  
7,c7 su* o!r entity z ! ,secret>y may   
specify ?r\gh rulemak+4  7#b7           
,applicable gr\p pur*as+ organization ,!
 t]m applicable gr\p pur*as+            
organization means a gr\p pur*as+       
organization t is affiliat$ ) or "u     
common own]%ip ) an entity provid+      
ph>macy b5efit managem5t s]vices4  7#c7 
,contract$ comp5sation ,! t]m contract$ 
comp5sation means ! sum ( any +r$i5t co/
 & disp5s+ fee = a drug 7inclusive ( !  
out-(-pocket co/s to ! p>ticipant or    
b5efici>y71 or ano!r analog\s           

comp5sation /ructure t ! ,secret>y may  
specify ?r\gh regulations4  7#d7 ,gross 
sp5d+ ,! t]m gross sp5d+1 ) respect to  
prescription drug b5efits "u a gr\p     
heal? plan or heal? insurance cov]age1  
means ! am\nt sp5t by a gr\p heal? plan 
or heal? insurance issu] on prescription
 drug b5efits1 calculat$ be=e !         
application ( rebates1 fees1 alt]native 
disc\nts1 or o!r remun]ation4  7#e7 ,net
 sp5d+ ,! t]m net sp5d+1 ) respect to   
prescription drug b5efits "u a gr\p     
heal? plan or heal? insurance cov]age1  
means ! am\nt sp5t by a gr\p heal? plan 
or heal? insurance issu] on prescription
 drug b5efits1 calculat$ aft] !         
application ( rebates1 fees1 alt]native 
disc\nts1 or o!r remun]ation4  7#f7     
,plan sponsor ,! t]m plan sponsor has ! 
mean+ giv5 su* t]m 9 section            
#c7af77;,b74  7#g7 ,remun]ation ,! t]m  
remun]ation has ! mean+ giv5 su* t]m by 
! ,secret>y ?r\gh rulemak+1 :i* %all be 
reevaluat$ by ! ,secret>y e #e ye>s4    
7#h7 ,specifi$ l>ge employ] ,! t]m      

#8specifi$ l>ge employ]' means1 9       
connection ) a gr\p heal? plan 7includ+ 
gr\p heal? insurance cov]age (f]$ 9     
connection ) su* a plan7 e/abli%$ or    
ma9ta9$ by a s+le employ]1 ) respect to 
a cal5d> ye> or a plan ye>1 z           
applicable1 an employ] :o employ$ an    
av]age ( at lea/ #ajj employees on      
bus9ess days dur+ ! prec$+ cal5d> ye> or
 plan ye> & :o employs at lea/ #a       
employee on ! fir/ day ( ! cal5d> ye> or
 plan ye>4  7#i7 ,specifi$ l>ge plan ,! 
t]m specifi$ l>ge plan means a gr\p     
heal? plan 7includ+ gr\p heal? insurance
 cov]age (f]$ 9 connection ) su* a plan7
 e/abli%$ or ma9ta9$ by a plan sponsor  
describ$ 9 clause 7ii7 or 7iii7 (       
section #c7af77;,b7 t _h an av]age ( at 
lea/ #ajj p>ticipants on bus9ess days   
dur+ ! prec$+ cal5d> ye> or plan ye>1 z 
applicable4  7#aj7 ,:olesale acquisition
 co/ ,! t]m :olesale acquisition co/ has
 ! mean+ giv5 su* t]m 9 section         
#ahdg;,a7c77#f77;,b7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           

#aciew-#c;a7c77#f77;,b774  2  7,b7 9    
section #ejb 7#bi ,u4,s4,c4 #aacb7-- 7i7
 9 subsection 7a77#f71 by /rik+ or 7#i7 
& ins]t+ 7#i71 or 7#ac72  7ii7 9        
subsection 7b77#c71 by /rik+ "u         
subsection 7c77#i7 & ins]t+ "u p>agraphs
 7#i7 & 7#ac7 ( subsection 7c72 &  7iii7
 9 subsection 7c71 by add+ at ! end !   
foll[+3  7#ac7 ,secret>ial en=cem5t     
au?ority relat+ to ov]sight ( ph>macy   
b5efit managem5t s]vices  7,a7 ,failure 
to provide in=mation ,! ,secret>y may   
impose a p5alty aga9/ a plan adm9i/rator
 ( a gr\p heal? plan1 a heal? insurance 
issu] (f]+ gr\p heal? insurance cov]age1
 or an entity provid+ ph>macy b5efit    
managem5t s]vices on behalf ( su* a plan
 or issu]1 or an applicable entity 7z   
def9$ 9 section #gbf7;f77 t violates    
section #gbf7;a72 an entity provid+     
ph>macy b5efit managem5t s]vices on     
behalf ( su* a plan or issu] t fails to 
provide ! in=mation requir$ "u section  
#gbf7;b72 or any p]son :o causes a gr\p 
heal? plan to fail to provide !         

in=mation requir$ "u section #gbf7;c71 9
 ! am\nt ( #aj1jjj = ea* day dur+ :i*   
su* violation cont9ues or su* in=mation 
is n disclos$ or report$4  7,b7 ,false  
in=mation ,! ,secret>y may impose a     
p5alty aga9/ a plan adm9i/rator ( a gr\p
 heal? plan1 a heal? insurance issu]    
(f]+ gr\p heal? insurance cov]age1 an   
entity provid+ ph>macy b5efit managem5t 
s]vices1 or an applicable entity 7z     
def9$ 9 section #gbf7;f77 t kn[+ly      
provides false in=mation "u section     
#gbf1 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 ( ?is       
section1 = an entity 9 violation (      
section #gbf t has made a good-fai? ef=t
 to comply ) ! requirem5ts ( section    
#gbf4  2 &  7,c7 9 section #gcb7;a7 7#bi
 ,u4,s4,c4 #aaia;a7a771 by /rik+ section
 #gaa & ins]t+ sections #gaa & #gbf4    

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 ( entities t provide ph>macy  
b5efit managem5t s]vices4  4  7c7       
,int]nal rev5ue code ( #aihf  7#a7 ,9   
g5]al ,*apt] #ajj ( ! ,int]nal ,rev5ue  
,code ( #aihf is am5d$ by add+ at ! end 
( sub*apt] ,b ! foll[+3  #ihbf4         
,ov]sight ( entities t provide ph>macy  
b5efit managem5t s]vices  7a7 ,9 g5]al  
,= plan ye>s beg9n+ on or aft] ! date t 
is #cj mon?s aft] ! date ( enactm5t (   
?is section 7ref]r$ to 9 ?is subsection 
& subsection 7b7 z ! effective date71 a 
gr\p heal? plan1 or an entity provid+   
ph>macy b5efit managem5t s]vices on     
behalf ( su* a plan1 %all n ent] into a 
contract1 includ+ an ext5sion or r5ewal 
( a contract1 ent]$ into on or aft] !   
effective date1 ) an applicable entity  
unless su* applicable entity agrees to--

 7#a7 n limit or delay ! disclosure (   
in=mation to ! gr\p heal? plan 9 su* a  
mann] t prev5ts an entity provid+       
ph>macy b5efit managem5t s]vices on     
behalf ( a gr\p heal? plan f mak+ !     
reports describ$ 9 subsection 7b72 &    
7#b7 provide ! entity provid+ ph>macy   
b5efit managem5t s]vices on behalf ( a  
gr\p heal? plan relevant in=mation      
necess>y to make ! reports describ$ 9   
subsection 7b74  7b7 ,reports  7#a7 ,9  
g5]al ,= plan ye>s beg9n+ on or aft] !  
effective date1 9 ! case ( any contract 
betwe5 a gr\p heal? plan & an entity    
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( su* plan1 includ+ an       
ext5sion or r5ewal ( su* a contract1    
ent]$ into on or aft] ! effective date1 
! entity provid+ ph>macy b5efit         
managem5t s]vices on behalf ( su* a gr\p
 heal? plan1 n less frequ5tly ?an e #f  
mon?s 7or1 at ! reque/ ( a gr\p heal?   
plan1 n less frequ5tly ?an qu>t]ly1 & "u
 ! same conditions1 t]ms1 & co/ ( !     
semiannual report "u ?is subsection71   

%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 pla9 language1 9 a   
ma*9e-readable =mat1 & z ! ,secret>y may
 det]m9e1 o!r =mats4 ,ea* su* report    
%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 ( a gr\p heal? plan t is (f]$ by a 
specifi$ l>ge employ] or t is a specifi$
 l>ge plan1 & is n (f]$ z heal?         
insurance cov]age1 or 9 ! case ( heal?  
insurance cov]age = :i* ! election "u   
p>agraph 7#c7 is made = ! applicable    
report+ p]iod--  7i7 a li/ ( drugs = :i*
 a claim 0 fil$ &1 ) respect to ea* su* 
drug on su* li/-- 7,i7 ! contract$      
comp5sation paid by ! gr\p heal? plan = 
ea* cov]$ drug 7id5tifi$ by ! ,national 
,drug ,code7 to ! entity provid+ ph>macy
 b5efit managem5t s]vices or o!r        

applicable entity on behalf ( ! gr\p    
heal? plan2  7,,ii7 ! contract$         
comp5sation paid to ! ph>macy1 by any   
entity provid+ ph>macy b5efit managem5t 
s]vices or o!r applicable entity on     
behalf ( ! gr\p heal? plan1 = ea* cov]$ 
drug 7id5tifi$ by ! ,national ,drug     
,code72  7,,iii7 = ea* su* claim1 !     
diff]5ce betwe5 ! am\nt paid "u         
subclause 7,i7 & ! am\nt paid "u        
subclause 7,,ii72  7,,iv7 ! propriet>y  
"n1 e/abli%$ "n or prop] "n1 & ,national
 ,drug ,code2  7,v7 = ea* claim = ! drug
 7includ+ orig9al prescriptions &       
refills7 & = ea* dosage unit ( ! drug = 
:i* a claim 0 fil$1 ! type ( disp5s+    
*annel us$ to furni% ! drug1 includ+    
retail1 mail ord]1 or specialty ph>macy2
  7,,vi7 ) respect to ea* drug disp5s$1 
= ea* type ( disp5s+ *annel 7includ+    
retail1 mail ord]1 or specialty         
ph>macy7-- 7aa7 :e!r su* drug is a br&  
"n drug or a g5]ic drug1 &-- 7,,aa7 9 ! 
case ( a br& "n drug1 ! :olesale        
acquisition co/1 li/$ 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$2 &  7bb7 ! total numb] (--      
7,,aa7 prescription claims 7includ+     
orig9al prescriptions & refills72 7,,bb7
 p>ticipants & b5efici>ies = :om a claim
 = su* drug 0 fil$ ?r\gh ! applicable   
disp5s+ *annel2 7,,cc7 dosage units &   
dosage units p] fill ( su* drug2 &      
7,,dd7 days supply ( su* drug p] fill2  
7,,vii7 ! net price p] c\rse ( treatm5t 
or s+le fill1 su* z a #cj-;day supply or
 #ij-;day supply to ! plan aft] rebates1
 fees1 alt]native disc\nts1 or o!r      
remun]ation receiv$ f applicable        
entities2  7,,viii7 ! total am\nt (     
out-(-pocket sp5d+ by p>ticipants &     
b5efici>ies on su* drug1 includ+ sp5d+  
?r\gh copaym5ts1 co9surance1 &          
d$uctibles1 b n includ+ any am\nts sp5t 
by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan1 or = :i* no claim is   

submitt$ "u ! plan2  7,,ix7 ! total net 
sp5d+ on ! drug2  7,x7 ! total am\nt    
receiv$1 or expect$ to be receiv$1 by ! 
plan f any applicable entity 9 rebates1 
fees1 alt]native disc\nts1 or o!r       
remun]ation2  7,,xi7 ! total am\nt      
receiv$1 or expect$ to be receiv$1 by ! 
entity provid+ ph>macy b5efit managem5t 
s]vices1 f applicable entities1 9       
rebates1 fees1 alt]native disc\nts1 or  
o!r remun]ation f su* entities--  7aa7 =
 claims incurr$ dur+ ! report+ p]iod2 & 
7bb7 t is relat$ to utilization ( su*   
drug or sp5d+ on su* drug2 &  7,,xii7 to
 ! ext5t feasible1 in=mation on ! total 
am\nt ( remun]ation = su* drug1 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/]+ copaym5t assi/ance on behalf ( 
su* drug manufactur]71 to ! p>ticipants 
& b5efici>ies enroll$ 9 su* plan2  7ii7 
a li/ ( ea* !rapeutic class 7z def9$ by 
! ,secret>y7 = :i* a claim 0 fil$ "u !  
gr\p heal? plan dur+ ! report+ p]iod1 &1

 ) respect to ea* su* !rapeutic class-- 
7,i7 ! total gross sp5d+ on drugs 9 su* 
class be=e rebates1 price concessions1  
alt]native disc\nts1 or o!r remun]ation 
f applicable entities2  7,,ii7 ! net    
sp5d+ 9 su* class aft] su* rebates1     
price concessions1 alt]native disc\nts1 
or o!r remun]ation f applicable         
entities2  7,,iii7 ! total am\nt        
receiv$1 or expect$ to be receiv$1 by ! 
entity provid+ ph>macy b5efit managem5t 
s]vices1 f applicable entities1 9       
rebates1 fees1 alt]native disc\nts1 or  
o!r remun]ation f su* entities-- 7aa7 = 
claims incurr$ dur+ ! report+ p]iod2 &  
7bb7 t is relat$ to utilization ( drugs 
or drug sp5d+2  7,,iv7 ! av]age net     
sp5d+ p] #cj-;day supply & p] #ij-;day  
supply by ! plan & its p>ticipants &    
b5efici>ies1 among all drugs )9 !       
!rapeutic class = :i* a claim 0 fil$    
dur+ ! report+ p]iod2  7,v7 ! numb] (   
p>ticipants & b5efici>ies :o fill$ a    
prescription = a drug 9 su* class1      
includ+ ! ,national ,drug ,code = ea*   

su* drug2  7,,vi7 if applicable1 a      
description ( ! =mul>y ti]s &           
utilization me*anisms 7su* z prior      
au?orization or /ep !rapy7 employ$ =    
drugs 9 t class2 &  7,,vii7 ! total     
out-(-pocket sp5d+ "u ! plan by         
p>ticipants & b5efici>ies1 includ+ sp5d+
 ?r\gh copaym5ts1 co9surance1 &         
d$uctibles1 b n includ+ any am\nts sp5t 
by p>ticipants & b5efici>ies on drugs n 
cov]$ "u ! plan or = :i* no claim is    
submitt$ "u ! plan2  7iii7 ) respect to 
any drug = :i* gross sp5d+ "u ! gr\p    
heal? plan exce$$ #aj1jjj dur+ ! report+
 p]iod or1 9 ! case t gross sp5d+ "u !  
gr\p heal? plan exce$$ #aj1jjj dur+ !   
report+ p]iod ) respect to few] ?an #ej 
drugs1 ) respect to ! #ej prescription  
drugs ) ! highe/ sp5d+ dur+ ! report+   
p]iod--  7,i7 a li/ ( all o!r drugs 9 ! 
same !rapeutic class z su* drug2  7,,ii7
 if applicable1 ! rationale = ! =mul>y  
placem5t ( su* drug 9 t !rapeutic       
category or class1 select$ f a li/ (    
/&>d rationales e/abli%$ by ! ,secret>y1

 9 consultation ) /akehold]s2 &  7,,iii7
 any *ange 9 =mul>y placem5t comp>$ to !
 prior plan ye>2 &  7iv7 9 ! case t su* 
plan 7or an entity provid+ ph>macy      
b5efit managem5t s]vices on behalf ( su*
 plan7 has an affiliat$ ph>macy or      
ph>macy "u common own]%ip1 includ+      
m&atory mail & specialty home deliv]y   
programs1 retail & mail auto-refill     
programs1 & co/ %>+ assi/ance inc5tives 
fund$ by an entity provid+ ph>macy      
b5efit s]vices--  7,i7 an explanation ( 
any b5efit design p>amet]s t enc\rage or
 require p>ticipants & b5efici>ies 9 !  
plan to fill prescriptions at mail ord]1
 specialty1 or retail ph>macies2  7,,ii7
 ! p]c5tage ( total prescriptions       
disp5s$ by su* ph>macies to p>ticipants 
or b5efici>ies 9 su* plan2 &  7,,iii7 a 
li/ ( all drugs disp5s$ by su* ph>macies
 to p>ticipants or b5efici>ies 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>ticipants & b5efici>ies2  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>ticipants &  
b5efici>ies1 :5 ! same drug is disp5s$  
by o!r ph>macies t are n affiliat$ ) or 
"u common own]%ip ) ! entity & t are    
includ$ 9 ! ph>macy network ( su* plan2 
7cc7 ! l[e/ co/ p] dosage unit1 p]      
#cj-;day supply & p] #ij-;day supply1 = 
ea* su* drug1 includ+ am\nts *>g$ to !  
plan & to p>ticipants & b5efici>ies1 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 ) respect to any 
gr\p heal? plan1 reg>dless ( :e!r ! plan
 is (f]$ by a specifi$ l>ge employ] or  
:e!r x is a specifi$ l>ge plan--  7i7 a 
summ>y docum5t = ! gr\p heal? plan t    
includes su* in=mation describ$ 9       
clauses 7i7 ?r\gh 7iv7 ( subp>agraph    

7,a71 z specifi$ by ! ,secret>y ?r\gh   
guidance1 program in/ruction1 or o!rwise
 7) no requirem5t ( notice & comm5t     
rulemak+71 t ! ,secret>y det]m9es useful
 to gr\p heal? plans = purposes (       
select+ ph>macy b5efit managem5t        
s]vices1 su* z an e/imat$ net price to  
gr\p heal? plan & p>ticipant or         
b5efici>y1 a co/ p] claim1 ! fee        
/ructure or reimbursem5t model1 &       
e/imat$ co/ p] p>ticipant or b5efici>y2 
7ii7 a summ>y docum5t = plans to provide
 to p>ticipants & b5efici>ies1 :i* %all 
be made available to p>ticipants or     
b5efici>ies ^u reque/ to _! gr\p heal?  
plan1 t--  7,i7 conta9s su* in=mation   
describ$ 9 clauses 7iii71 7iv71 7v71 &  
7vi71 z applicable1 z specifi$ by !     
,secret>y ?r\gh guidance1 program       
in/ruction1 or o!rwise 7) no requirem5t 
( notice & comm5t rulemak+7 t !         
,secret>y det]m9es useful to p>ticipants
 or b5efici>ies 9 bett] und]/&+ ! plan  
or b5efits "u su* plan2  7,,ii7 conta9s 
only aggregate in=mation2 &  7,,iii7    

/ates t p>ticipants & b5efici>ies may   
reque/ specific1 claims-level in=mation 
requir$ to be furni%$ "u subsection 7c7 
f ! gr\p heal? plan2  7iii7 ) respect to
 drugs cov]$ by su* plan dur+ su*       
report+ p]iod--  7,i7 ! total net sp5d+ 
by ! plan = all su* drugs2  7,,ii7 !    
total am\nt receiv$1 or expect$ to be   
receiv$1 by ! plan f any applicable     
entity 9 rebates1 fees1 alt]native      
disc\nts1 or o!r remun]ation2 &  7,,iii7
 to ! ext5t feasible1 in=mation on !    
total am\nt ( remun]ation = su* drugs1  
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/]+ copaym5t assi/ance on   
behalf ( su* drug manufactur]7 to       
p>ticipants & b5efici>ies2  7iv7 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  
,act 7#bi ,u4,s4,c4                     

#aajh7;b77#b77;,b77ii77dd77,,aa777 to   
brok]age firms1 brok]s1 consultants1    
advisors1 or any o!r individual or firm1
 =--  7,i7 ! ref]ral ( ! gr\p heal?     
plan's bus9ess to an entity provid+     
ph>macy b5efit managem5t s]vices1       
includ+ ! id5tity ( ! recipi5t ( su*    
am\nts2  7,,ii7 consid]ation ( ! entity 
provid+ ph>macy b5efit managem5t s]vices
 by ! gr\p heal? plan2 or  7,,iii7 !    
ret5tion ( ! entity by ! gr\p heal?     
plan2  7v7 an explanation ( any b5efit  
design p>amet]s t enc\rage or require   
p>ticipants & b5efici>ies 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 &  7vi7 
total gross sp5d+ on all drugs "u ! plan
 dur+ ! report+ p]iod4  7#c7 ,opt-9 =   

gr\p heal? insurance cov]age (f]$ by a  
specifi$ l>ge employ] or t is a specifi$
 l>ge plan ,9 ! case ( gr\p heal?       
insurance cov]age (f]$ 9 connection ) a 
gr\p heal? plan t is (f]$ by a specifi$ 
l>ge employ] or is a specifi$ l>ge plan1
 su* gr\p heal? plan may1 on an annual  
basis1 = plan ye>s beg9n+ on or aft] !  
date t is #cj mon?s aft] ! date (       
enactm5t ( ?is section1 elect to require
 an entity provid+ ph>macy b5efit       
managem5t s]vices on behalf ( ! heal?   
insurance issu] to submit to su* gr\p   
heal? plan a report t includes all ( !  
in=mation describ$ 9 p>agraph 7#b77;,a71
 9 addition to ! in=mation describ$ 9   
p>agraph 7#b77;,b74  7#d7 ,privacy      
requirem5ts  7,a7 ,9 g5]al ,an entity   
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( a gr\p heal? plan %all     
report in=mation "u p>agraph 7#a7 9 a   
mann] consi/5t ) ! privacy regulations  
promulgat$ "u section #acdjb7;a7 ( !    
,heal? ,in=mation ,te*nology = ,economic
 & ,cl9ical ,heal? ,act 7#db ,u4,s4,c4  

#agicb7;a77 & consi/5t ) ! privacy      
regulations promulgat$ "u ! ,heal?      
,insurance ,portability & ,acc\ntability
 ,act ( #aiif 9 "p #afj & subp>ts ,a &  
,e ( "p #afd ( title #de1 ,code ( ,f$]al
 ,regulations 7or successor regulations7
 7ref]r$ to 9 ?is p>agraph z ! ,,hipaa  
privacy regulations7 & %all re/rict !   
use & disclosure ( su* in=mation accord+
 to su* privacy regulations & su*       
,,hipaa privacy regulations4  7,b7      
,additional requirem5ts  7i7 ,9 g5]al   
,an entity provid+ ph>macy b5efit       
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$]al ,regulations 7or    
successor regulations74  7ii7           
,re/rictions ,9 c>ry+ out ?is           
subsection1 a gr\p heal? plan %all      
comply ) section #afd4ejd7;f7 ( title   
#de1 ,code ( ,f$]al ,regulations 7or a  
successor regulation71 & a plan sponsor 

%all act 9 accordance ) ! t]ms ( !      
agreem5t describ$ 9 su* section4  7,c7  
,rule ( con/ruction  7i7 ,no?+ 9 ?is    
section %all be con/ru$ to modify !     
requirem5ts = ! creation1 receipt1      
ma9t5ance1 or transmission ( protect$   
heal? in=mation "u ! ,,hipaa privacy    
regulations4  7ii7 ,no?+ 9 ?is section  
%all be con/ru$ to affect ! application 
( any ,f$]al or ,/ate privacy or civil  
rights law1 includ+ ! ,,hipaa privacy   
regulations1 ! ,g5etic ,in=mation       
,nondiscrim9ation ,act ( #bjjh 7,public 
,law #aaj-bcc7 7includ+ ! am5dm5ts made 
by su* ,act71 ! ,am]icans )             
,disabilities ,act ( #aiij 7#db         
,u4,s4,c4 #abaja et seq471 section #ejd 
( ! ,rehabilitation ,act ( #aigc 7#bi   
,u4,s4,c4 #gid71 section #aeeg ( !      
,pati5t ,protection & ,af=dable ,c>e    
,act 7#db ,u4,s4,c4 #ahaaf71 title ,,vi 
( ! ,civil ,rights ,act ( #aifd 7#db    
,u4,s4,c4 #bjjj;d71 & title ,,vii ( !   
,civil ,rights ,act ( #aifd 7#db        
,u4,s4,c4 #bjjj;e74  7,d7 ,writt5 notice

 ,ea* plan ye>1 gr\p heal? plans %all   
provide to ea* p>ticipant or b5efici>y  
writt5 notice in=m+ ! p>ticipant or     
b5efici>y ( ! requirem5t = entities     
provid+ ph>macy b5efit managem5t s]vices
 on behalf ( ! gr\p heal? plan to submit
 reports to gr\p heal? plans "u p>agraph
 7#a71 z applicable1 :i* may include    
incorporat+ su* notification 9 plan     
docum5ts provid$ to ! p>ticipant or     
b5efici>y1 or provid+ individual        
notification4  7,e7 ,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 regulations4  7,f7 ,cl>ification
 reg>d+ public disclosure ( in=mation   
,no?+ 9 ?is section %all prev5t an      
entity provid+ ph>macy b5efit managem5t 
s]vices on behalf ( a gr\p heal? plan1 f

 plac+ reasonable re/rictions on !      
public disclosure ( ! in=mation conta9$ 
9 a report describ$ 9 p>agraph 7#a71    
except t su* plan or entity may n--  7i7
 re/rict disclosure ( su* report to !   
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,dep>tm5t ( ,labor1 or ! ,dep>tm5t ( !  
,treasury2 or  7ii7 prev5t disclosure = 
! purposes ( subsection 7c71 or any o!r 
public disclosure requirem5t "u ?is     
section4  7,g7 ,limit$ =m ( report ,!   
,secret>y %all def9e ?r\gh rulemak+ a   
limit$ =m ( ! report "u p>agraph 7#a7   
requir$ ) respect to any gr\p heal? plan
 e/abli%$ by a plan sponsor t is1 or is 
affiliat$ )1 a drug manufactur]1 drug   
:olesal]1 or o!r direct p>ticipant 9 !  
drug supply *a91 9 ord] to prev5t       
anti-competitive behavior4  7#e7 ,/&>d  
=mat & regulations  7,a7 ,9 g5]al ,n    
lat] ?an #ah mon?s aft] ! date (        
enactm5t ( ?is section1 ! ,secret>y %all
 specify ?r\gh rulemak+ a /&>d =mat =   
entities provid+ ph>macy b5efit         
managem5t s]vices on behalf ( gr\p heal?

 plans1 to submit reports requir$ "u    
p>agraph 7#a74  7,b7 ,additional        
regulations ,n lat] ?an #ah mon?s aft] !
 date ( enactm5t ( ?is section1 !       
,secret>y %all1 ?r\gh rulemak+1         
promulgate any o!r f9al regulations     
necess>y to implem5t ! requirem5ts ( ?is
 section4 ,9 promulgat+ su* regulations1
 ! ,secret>y %all1 to ! ext5t           
practicable1 align ! report+ requirem5ts
 "u ?is section ) ! report+ requirem5ts 
"u section #ihbe4  7c7 ,requirem5t ,to  
provide in=mation to p>ticipants or     
b5efici>ies ,a gr\p heal? plan1 ^u      
reque/ ( a p>ticipant or b5efici>y1 %all
 provide to su* p>ticipant or           
b5efici>y--  7#a7 ! summ>y docum5t      
describ$ 9 subsection 7b77#b77;,b77ii72 
&  7#b7 ! in=mation describ$ 9          
subsection 7b77#b77;,a77i77,,iii7 )     
respect to a claim made by or on behalf 
( su* p>ticipant or b5efici>y4  7d7     
,rule ( con/ruction ,no?+ 9 ?is section 
%all be con/ru$ to p]mit a heal?        
insurance issu]1 gr\p heal? plan1 entity

 provid+ ph>macy b5efit managem5t       
s]vices on behalf ( a gr\p heal? plan or
 heal? insurance issu]1 or o!r entity to
 re/rict disclosure to1 or o!rwise limit
 ! access (1 ! ,secret>y to a report    
describ$ 9 subsection 7b77#a7 or        
in=mation relat$ to compliance )        
subsections 7a71 7b71 or 7c7 ( ?is      
section or section #dihj;,d7g7 by su*   
issu]1 plan1 or entity4  7e7 ,def9itions
 ,9 ?is section3  7#a7 ,applicable      
entity ,! t]m applicable entity means-- 
7,a7 an applicable gr\p pur*as+         
organization1 drug manufactur]1         
di/ributor1 :olesal]1 rebate aggregator 
7or o!r pur*as+ entity design$ to       
aggregate rebates71 or associat$ ?ird   
p>ty2  7,b7 any subsidi>y1 p>5t1        
affiliate1 or subcontractor ( a gr\p    
heal? plan1 heal? insurance issu]1      
entity t provides ph>macy b5efit        
managem5t s]vices on behalf ( su* a plan
 or issu]1 or any entity describ$ 9     
subp>agraph 7,a72 or  7,c7 su* o!r      
entity z ! ,secret>y may specify ?r\gh  

rulemak+4  7#b7 ,applicable gr\p pur*as+
 organization ,! t]m applicable gr\p    
pur*as+ organization means a gr\p       
pur*as+ organization t is affiliat$ ) or
 "u common own]%ip ) an entity provid+  
ph>macy b5efit managem5t s]vices4  7#c7 
,contract$ comp5sation ,! t]m contract$ 
comp5sation means ! sum ( any +r$i5t co/
 & disp5s+ fee = a drug 7inclusive ( !  
out-(-pocket co/s to ! p>ticipant or    
b5efici>y71 or ano!r analog\s           
comp5sation /ructure t ! ,secret>y may  
specify ?r\gh regulations4  7#d7 ,gross 
sp5d+ ,! t]m gross sp5d+1 ) respect to  
prescription drug b5efits "u a gr\p     
heal? plan1 means ! am\nt sp5t by a gr\p
 heal? plan on prescription drug        
b5efits1 calculat$ be=e ! application ( 
rebates1 fees1 alt]native disc\nts1 or  
o!r remun]ation4  7#e7 ,net sp5d+ ,! t]m
 net sp5d+1 ) respect to prescription   
drug b5efits "u a gr\p heal? plan1 means
 ! am\nt sp5t by a gr\p heal? plan on   
prescription drug b5efits1 calculat$    
aft] ! application ( rebates1 fees1     

alt]native disc\nts1 or o!r remun]ation4
  7#f7 ,plan sponsor ,! t]m plan sponsor
 has ! mean+ giv5 su* t]m 9 section     
#c7af77;,b7 ( ! ,employee ,retirem5t    
,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #ajjb7af77;,b774  7#g7        
,remun]ation ,! t]m remun]ation has !   
mean+ giv5 su* t]m by ! ,secret>y1 ?r\gh
 rulemak+1 :i* %all be reevaluat$ by !  
,secret>y e #e ye>s4  7#h7 ,specifi$    
l>ge employ] ,! t]m specifi$ l>ge       
employ] means1 9 connection ) a gr\p    
heal? plan e/abli%$ or ma9ta9$ by a s+le
 employ]1 ) respect to a cal5d> ye> or a
 plan ye>1 z applicable1 an employ] :o  
employ$ an av]age ( at lea/ #ajj        
employees on bus9ess days dur+ ! prec$+ 
cal5d> ye> or plan ye> & :o employs at  
lea/ #a employee on ! fir/ day ( !      
cal5d> ye> or plan ye>4  7#i7 ,specifi$ 
l>ge plan ,! t]m specifi$ l>ge plan     
means a gr\p heal? plan e/abli%$ or     
ma9ta9$ by a plan sponsor describ$ 9    
clause 7ii7 or 7iii7 ( section          
#c7af77;,b7 ( ! ,employee ,retirem5t    

,income ,security ,act ( #aigd 7#bi     
,u4,s4,c4 #ajjb7af77;,b77 t _h an av]age
 ( at lea/ #ajj p>ticipants on bus9ess  
days dur+ ! prec$+ cal5d> ye> or plan   
ye>1 z applicable4  7#aj7 ,:olesale     
acquisition co/ ,! t]m :olesale         
acquisition co/ has ! mean+ giv5 su* t]m
 9 section #ahdg;,a7c77#f77;,b7 ( !     
,social ,security ,act 7#db ,u4,s4,c4   
#aciew-#c;a7c77#f77;,b774  4  7#b7      
,exception = c]ta9 gr\p heal? plans     
,section #ihca7;a77#b7 ( ! ,int]nal     
,rev5ue ,code ( #aihf is am5d$ by ins]t+
 o!r ?an ) respect to section #ihbf1    
be=e any gr\p heal? plan4  7#c7         
,en=cem5t ,section #dihj;,d ( ! ,int]nal
 ,rev5ue ,code ( #aihf is am5d$ by add+ 
at ! end ! foll[+ new subsection3  7g7  
,application to requirem5ts impos$ on   
c]ta9 entities provid+ ph>macy b5efit   
managem5t s]vices ,9 ! case ( any       
requirem5t "u section #ihbf t applies ) 
respect to an entity provid+ ph>macy    
b5efit managem5t s]vices on behalf ( a  
gr\p heal? plan1 any ref]5ce 9 ?is      

section to su* gr\p heal? plan 7& !     
ref]5ce 9 subsection 7e77#a7 to !       
employ]7 %all be treat$ z includ+ a     
ref]5ce to su* entity4  4  7#d7 ,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 ( entities t provide ph>macy  
b5efit managem5t s]vices4  4  #bjb4     
,fund+ co/ %>+ r$uction paym5ts ,section
 #adjb ( ! ,pati5t ,protection &        
,af=dable ,c>e ,act 7#db ,u4,s4,c4      
#ahjga7 is am5d$ by add+ at ! end !     
foll[+ new subsection3  7h7 ,fund+  7#a7
 ,9 g5]al ,!re are appropriat$ out ( any
 monies 9 ! ,treasury n o!rwise         
appropriat$ su* sums z may be necess>y =
 purposes ( mak+ paym5ts "u ?is section 
= plan ye>s beg9n+ on or aft] ,janu>y   
#a1 #bjbg4  7#b7 ,limitation  7,a7 ,9   
g5]al ,! am\nts appropriat$ "u p>agraph 
7#a7 may n be us$ = purposes ( mak+     
paym5ts "u ?is section = a qualifi$     
heal? plan t provides heal? b5efit      

cov]age t includes cov]age ( abortion4  
7,b7 ,exception ,subp>agraph 7,a7 %all n
 apply to paym5ts = a qualifi$ heal?    
plan t provides cov]age ( abortion only 
if necess>y to save ! life ( ! "m or if 
! pregnancy is a result ( an act ( rape 
or ince/4  4