Alternative prescription drug coverage requirements
A prescription drug plan or an MA–PD plan may provide a different prescription drug benefit design from standard prescription drug coverage so long as the Secretary determines (consistent with section 1395w–111(c) of this title ) that the following requirements are met and the plan applies for, and receives, the approval of the Secretary for such benefit design:
(1) Assuring at least actuarially equivalent coverage
(1)Assuring at least actuarially equivalent coverage#
(A) Assuring equivalent value of total coverage The actuarial value of the total coverage is at least equal to the actuarial value of standard prescription drug coverage.
(B) Assuring equivalent unsubsidized value of coverage The unsubsidized value of the coverage is at least equal to the unsubsidized value of standard prescription drug coverage. For purposes of this subparagraph, the unsubsidized value of coverage is the amount by which the actuarial value of the coverage exceeds the actuarial value of the subsidy payments under section 1395w–115 of this title with respect to such coverage.
(C) Assuring standard payment for costs The coverage is designed, based upon an actuarially representative pattern of utilization, to provide for the payment, with respect to costs incurred that are equal to the initial coverage limit under subsection (b)(3) for the year for a year preceding 2025 or the annual out-of-pocket threshold specified in subsection (b)(4)(B) for the year for 2025 and each subsequent year, of an amount equal to at least the product of— (i) the amount by which the initial coverage limit described in subsection (b)(3) for the year for a year preceding 2025 or the annual out-of-pocket threshold specified in subsection (b)(4)(B) for the year for 2025 and each subsequent year exceeds the deductible described in subsection (b)(1) for the year; and (ii) 100 percent minus the coinsurance percentage specified in subsection (b)(2)(A)(i).
(1)(A)Assuring equivalent value of total coverage#
The actuarial value of the total coverage is at least equal to the actuarial value of standard prescription drug coverage.
(1)(B)
(2)Maximum required deductible#
The deductible under the coverage shall not exceed the deductible amount specified under subsection (b)(1) for the year.
(3)Same protection against high out-of-pocket expenditures#
The coverage provides the coverage required under subsection (b)(4).
(4)Same maximum monthly cap on cost-sharing#
The maximum monthly cap on cost-sharing payments shall apply to coverage with respect to an enrollee who has made an election pursuant to clause (i) of subsection (b)(2)(E) under the option provided under such subsection.
(5)Treatment of cost-sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices#
The coverage is in accordance with subsection (b)(8).
(6)Treatment of cost-sharing for covered insulin products#
The coverage is provided in accordance with subsection (b)(9).