(a) Provision of informationA health benefits plan or any entity that provides pharmacy benefits management services on behalf of a health benefits plan (in this section referred to as a “PBM”) that manages prescription drug coverage under a contract with—(1) a PDP sponsor of a prescription drug plan or an MA organization offering an MA–PD plan under part D of subchapter XVIII; or
(2) a qualified health benefits plan offered through an exchange established by a State under section 18031 of this title,
shall provide the information described in subsection (b) to the Secretary and, in the case of a PBM, to the plan with which the PBM is under contract with, at such times, and in such form and manner, as the Secretary shall specify.
(b) Information describedThe information described in this subsection is the following with respect to services provided by a health benefits plan or PBM for a contract year:(1) The percentage of all prescriptions that were provided through retail pharmacies compared to mail order pharmacies, and the percentage of prescriptions for which a generic drug was available and dispensed (generic dispensing rate), by pharmacy type (which includes an independent pharmacy, chain pharmacy, supermarket pharmacy, or mass merchandiser pharmacy that is licensed as a pharmacy by the State and that dispenses medication to the general public), that is paid by the health benefits plan or PBM under the contract.
(2) The aggregate amount, and the type of rebates, discounts, or price concessions (excluding bona fide service fees, which include but are not limited to distribution service fees, inventory management fees, product stocking allowances, and fees associated with administrative services agreements and patient care programs (such as medication compliance programs and patient education programs)) that the PBM negotiates that are attributable to patient utilization under the plan, and the aggregate amount of the rebates, discounts, or price concessions that are passed through to the plan sponsor, and the total number of prescriptions that were dispensed.
(3) The aggregate amount of the difference between the amount the health benefits plan pays the PBM and the amount that the PBM pays retail pharmacies, and mail order pharmacies, and the total number of prescriptions that were dispensed.
(c) ConfidentialityInformation disclosed by a health benefits plan or PBM under this section is confidential and shall not be disclosed by the Secretary or by a plan receiving the information, except that the Secretary may disclose the information in a form which does not disclose the identity of a specific PBM, plan, or prices charged for drugs, for the following purposes:(1) As the Secretary determines to be necessary to carry out this section or part D of subchapter XVIII.
(2) To permit the Comptroller General to review the information provided.
(3) To permit the Director of the Congressional Budget Office to review the information provided.
(4) To States to carry out section 18031 of this title.
(d) PenaltiesThe provisions of subsection (b)(3)(C) of section 1396r–8 of this title shall apply to a health benefits plan or PBM that fails to provide information required under subsection (a) on a timely basis or that knowingly provides false information in the same manner as such provisions apply to a manufacturer with an agreement under that section.
Structure US Code
Title 42— THE PUBLIC HEALTH AND WELFARE
SUBCHAPTER XI— GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION
§ 1304. Reservation of right to amend or repeal
§ 1305. Short title of chapter
§ 1306a. Public access to State disbursement records
§ 1306c. Restriction on access to the Death Master File
§ 1310. Cooperative research or demonstration projects
§ 1311. Public assistance payments to legal representatives
§ 1312. Medical care guides and reports for public assistance and medical assistance
§ 1313. Assistance for United States citizens returned from foreign countries
§ 1314. Public advisory groups
§ 1314a. Measurement and reporting of welfare receipt
§ 1315. Demonstration projects
§ 1315a. Center for Medicare and Medicaid Innovation
§ 1315b. Providing Federal coverage and payment coordination for dual eligible beneficiaries
§ 1316. Administrative and judicial review of public assistance determinations
§ 1318. Alternative Federal payment with respect to public assistance expenditures
§ 1320. Approval of certain projects
§ 1320a. Uniform reporting systems for health services facilities and organizations
§ 1320a–1. Limitation on use of Federal funds for capital expenditures
§ 1320a–2. Effect of failure to carry out State plan
§ 1320a–3a. Disclosure requirements for other providers under part B of Medicare
§ 1320a–4. Issuance of subpenas by Comptroller General
§ 1320a–6. Adjustments in SSI benefits on account of retroactive benefits under subchapter II
§ 1320a–6a. Interagency coordination to improve program administration
§ 1320a–7a. Civil monetary penalties
§ 1320a–7b. Criminal penalties for acts involving Federal health care programs
§ 1320a–7c. Fraud and abuse control program
§ 1320a–7d. Guidance regarding application of health care fraud and abuse sanctions
§ 1320a–7e. Health care fraud and abuse data collection program
§ 1320a–7f. Coordination of medicare and medicaid surety bond provisions
§ 1320a–7g. Funds to reduce medicaid fraud and abuse
§ 1320a–7h. Transparency reports and reporting of physician ownership or investment interests
§ 1320a–7i. Reporting of information relating to drug samples
§ 1320a–7j. Accountability requirements for facilities
§ 1320a–7k. Medicare and Medicaid program integrity provisions
§ 1320a–8. Civil monetary penalties and assessments for subchapters II, VIII and XVI
§ 1320a–8a. Administrative procedure for imposing penalties for false or misleading statements
§ 1320a–8b. Attempts to interfere with administration of this chapter
§ 1320a–9. Demonstration projects
§ 1320a–10. Effect of failure to carry out State plan
§ 1320b–1. Notification of Social Security claimant with respect to deferred vested benefits
§ 1320b–2. Period within which certain claims must be filed
§ 1320b–4. Nonprofit hospital or critical access hospital philanthropy
§ 1320b–5. Authority to waive requirements during national emergencies
§ 1320b–7. Income and eligibility verification system
§ 1320b–8. Hospital protocols for organ procurement and standards for organ procurement agencies
§ 1320b–9a. Child health quality measures
§ 1320b–9b. Adult health quality measures
§ 1320b–10. Prohibitions relating to references to Social Security or Medicare
§ 1320b–11. Blood donor locator service
§ 1320b–12. Research on outcomes of health care services and procedures
§ 1320b–13. Social security account statements
§ 1320b–15. Protection of social security and medicare trust funds
§ 1320b–17. Cross-program recovery of overpayments from benefits
§ 1320b–19. The Ticket to Work and Self-Sufficiency Program
§ 1320b–20. Work incentives outreach program
§ 1320b–21. State grants for work incentives assistance to disabled beneficiaries
§ 1320b–23. Pharmacy benefit managers transparency requirements
§ 1320b–24. Consultation with Tribal Technical Advisory Group