Requirements
(1) In general
(1)In general#
For purposes of this part and part C, the term “qualified prescription drug coverage” means either of the following:
(A) Standard prescription drug coverage with access to negotiated prices Standard prescription drug coverage (as defined in subsection (b)) and access to negotiated prices under subsection (d).
(B) Alternative prescription drug coverage with at least actuarially equivalent benefits and access to negotiated prices Coverage of covered part D drugs which meets the alternative prescription drug coverage requirements of subsection (c) and access to negotiated prices under subsection (d), but only if the benefit design of such coverage is approved by the Secretary, as provided under subsection (c).
(1)(A)Standard prescription drug coverage with access to negotiated prices#
Standard prescription drug coverage (as defined in subsection (b)) and access to negotiated prices under subsection (d).
(1)(B)Alternative prescription drug coverage with at least actuarially equivalent benefits and access to negotiated prices#
Coverage of covered part D drugs which meets the alternative prescription drug coverage requirements of subsection (c) and access to negotiated prices under subsection (d), but only if the benefit design of such coverage is approved by the Secretary, as provided under subsection (c).
(2)Permitting supplemental prescription drug coverage#
(A) In general Subject to subparagraph (B), qualified prescription drug coverage may include supplemental prescription drug coverage consisting of either or both of the following: (i) Certain reductions in cost-sharing (I) In general A reduction in the annual deductible, a reduction in the coinsurance percentage or, for a year preceding 2025, an increase in the initial coverage limit with respect to covered part D drugs, or any combination thereof, insofar as such a reduction or increase increases the actuarial value of benefits above the actuarial value of basic prescription drug coverage. (II) Construction Nothing in this paragraph shall be construed as affecting the application of subsection (c)(3). (ii) Optional drugs Coverage of any product that would be a covered part D drug but for the application of subsection (e)(2)(A).
(B) Requirement A PDP sponsor may not offer a prescription drug plan that provides supplemental prescription drug coverage pursuant to subparagraph (A) in an area unless the sponsor also offers a prescription drug plan in the area that only provides basic prescription drug coverage.
(2)(A)In general#
Subject to subparagraph (B), qualified prescription drug coverage may include supplemental prescription drug coverage consisting of either or both of the following:
(i) Certain reductions in cost-sharing (I) In general A reduction in the annual deductible, a reduction in the coinsurance percentage or, for a year preceding 2025, an increase in the initial coverage limit with respect to covered part D drugs, or any combination thereof, insofar as such a reduction or increase increases the actuarial value of benefits above the actuarial value of basic prescription drug coverage. (II) Construction Nothing in this paragraph shall be construed as affecting the application of subsection (c)(3).
(ii) Optional drugs Coverage of any product that would be a covered part D drug but for the application of subsection (e)(2)(A).
(3)Basic prescription drug coverage#
For purposes of this part and part C, the term “basic prescription drug coverage” means either of the following:
(A) Coverage that meets the requirements of paragraph (1)(A).
(B) Coverage that meets the requirements of paragraph (1)(B) but does not have any supplemental prescription drug coverage described in paragraph (2)(A).
(3)(A)#
Coverage that meets the requirements of paragraph (1)(A).
(3)(B)#
Coverage that meets the requirements of paragraph (1)(B) but does not have any supplemental prescription drug coverage described in paragraph (2)(A).
(4)Application of secondary payor provisions#
The provisions of section 1395w–22(a)(4) of this title shall apply under this part in the same manner as they apply under part C.
(5)Construction#
Nothing in this subsection shall be construed as changing the computation of incurred costs under subsection (b)(4).