Requirement for point-of-sale discounts

(a) Point-of-sale discounts. Part D sponsors must provide applicable discounts on applicable drugs at the point of sale on behalf of the manufacturer. As part of this process, plan sponsors must determine—

(1) Whether an enrollee is an applicable beneficiary as described in § 423.100;

(2) Whether a drug is an applicable drug as described in § 423.100; and

(3) The amount of the discount, in accordance with § 423.2712.

(b) Direct member reimbursement (DMR). Part D sponsors must provide applicable discounts on claims for applicable drugs submitted by applicable beneficiaries as DMRs, including out-of-network and in-network paper claims, if such claims are payable under the Part D plan. While the sponsor must account for the discount in adjudicating the DMR request and the associated PDE submitted to CMS, the point-of-sale requirement does not apply.

(c) Pharmacy prompt payment. Part D sponsors must reimburse a network pharmacy (as defined in § 423.100) the amount of the applicable discount within the applicable number of calendar days (as defined in § 423.100) of the date of dispensing (as defined in § 423.100) of an applicable drug, consistent with § 423.520.