{"identifier":"/us/usc/t42/s1395w\u2013151","title":42,"num":"\u00a7\u202f1395w\u2013151.","heading":"Definitions; treatment of references to provisions in part C","text":"\u00a7\u202f1395w\u2013151.\nDefinitions; treatment of references to provisions in part C\n(a)\nDefinitions\nFor purposes of this part:\n(1)\nBasic prescription drug coverage\nThe term \u201cbasic prescription drug coverage\u201d is defined in\nsection 1395w\u2013102(a)(3) of this title\n(2)\nCovered part D drug\nThe term \u201ccovered part D drug\u201d is defined in\nsection 1395w\u2013102(e) of this title\n(3)\nCreditable prescription drug coverage\nThe term \u201ccreditable prescription drug coverage\u201d has the meaning given such term in\nsection 1395w\u2013113(b)(4) of this title\n(4)\nPart D eligible individual\nThe term \u201cpart D eligible individual\u201d has the meaning given such term in\nsection 1395w\u2013101(a)(3)(A) of this title\n1\n1 See References in Text note below.\n(5)\nFallback prescription drug plan\nThe term \u201cfallback prescription drug plan\u201d has the meaning given such term in\nsection 1395w\u2013111(g)(4) of this title\n(6)\nInitial coverage limit\nThe term \u201cinitial coverage limit\u201d means such limit as established under\nsection 1395w\u2013102(b)(3) of this title\n(7)\nInsurance risk\nThe term \u201cinsurance risk\u201d means, with respect to a participating pharmacy, risk of the type commonly assumed only by insurers licensed by a State and does not include payment variations designed to reflect performance-based measures of activities within the control of the pharmacy, such as formulary compliance and generic drug substitution.\n(8)\nMA plan\nThe term \u201cMA plan\u201d has the meaning given such term in\nsection 1395w\u2013101(a)(3)(B) of this title\n1\n(9)\nMA\u2013PD plan\nThe term \u201cMA\u2013PD plan\u201d has the meaning given such term in\nsection 1395w\u2013101(a)(3)(C) of this title\n1\n(10)\nMedicare Prescription Drug Account\nThe term \u201cMedicare Prescription Drug Account\u201d means the Account created under\nsection 1395w\u2013116(a) of this title\n(11)\nPDP approved bid\nThe term \u201cPDP approved bid\u201d has the meaning given such term in\nsection 1395w\u2013113(a)(6) of this title\n(12)\nPDP region\nThe term \u201cPDP region\u201d means such a region as provided under\nsection 1395w\u2013111(a)(2) of this title\n(13)\nPDP sponsor\nThe term \u201cPDP sponsor\u201d means a nongovernmental entity that is certified under this part as meeting the requirements and standards of this part for such a sponsor.\n(14)\nPrescription drug plan\nThe term \u201cprescription drug plan\u201d means prescription drug coverage that is offered\u2014\n(A) under a policy, contract, or plan that has been approved under\nsection 1395w\u2013111(e) of this title\n(B) by a PDP sponsor pursuant to, and in accordance with, a contract between the Secretary and the sponsor under\nsection 1395w\u2013112(b) of this title\n(15)\nQualified prescription drug coverage\nThe term \u201cqualified prescription drug coverage\u201d is defined in\nsection 1395w\u2013102(a)(1) of this title\n(16)\nStandard prescription drug coverage\nThe term \u201cstandard prescription drug coverage\u201d is defined in\nsection 1395w\u2013102(b) of this title\n(17)\nState Pharmaceutical Assistance Program\nThe term \u201cState Pharmaceutical Assistance Program\u201d has the meaning given such term in\nsection 1395w\u2013133(b) of this title\n(18)\nSubsidy eligible individual\nThe term \u201csubsidy eligible individual\u201d has the meaning given such term in\nsection 1395w\u2013114(a)(3)(A) of this title\n(b)\nApplication of part C provisions under this part\nFor purposes of applying provisions of part C under this part with respect to a prescription drug plan and a PDP sponsor, unless otherwise provided in this part such provisions shall be applied as if\u2014\n(1) any reference to an MA plan included a reference to a prescription drug plan;\n(2) any reference to an MA organization or a provider-sponsored organization included a reference to a PDP sponsor;\n(3) any reference to a contract under\nsection 1395w\u201327 of this title\nsection 1395w\u2013112(b) of this title\n(4) any reference to part C included a reference to this part; and\n(5) any reference to an election period under\nsection 1395w\u201321 of this title\nsection 1395w\u2013101 of this title","url":"https://projectusc.org/usc/t42/s1395w\u2013151.html","content":[{"t":"sec","id":"/us/usc/t42/s1395w\u2013151","children":[{"t":"num","text":"\u00a7\u202f1395w\u2013151."},{"t":"heading","text":"Definitions; treatment of references to provisions in part C"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013151/a","children":[{"t":"num","text":"(a)"},{"t":"heading","text":"Definitions"},{"t":"chapeau","text":"For purposes of this part:"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Basic prescription drug coverage"},{"t":"content","children":[{"t":"p","text":"The term \u201cbasic prescription drug coverage\u201d is defined in ","children":[{"t":"ref","text":"section 1395w\u2013102(a)(3) of this title","href":"/us/usc/t42/s1395w\u2013102/a/3","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Covered part D drug"},{"t":"content","children":[{"t":"p","text":"The term \u201ccovered part D drug\u201d is defined in ","children":[{"t":"ref","text":"section 1395w\u2013102(e) of this title","href":"/us/usc/t42/s1395w\u2013102/e","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Creditable prescription drug coverage"},{"t":"content","children":[{"t":"p","text":"The term \u201ccreditable prescription drug coverage\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013113(b)(4) of this title","href":"/us/usc/t42/s1395w\u2013113/b/4","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/4","children":[{"t":"num","text":"(4)"},{"t":"heading","text":"Part D eligible individual"},{"t":"content","children":[{"t":"p","text":"The term \u201cpart D eligible individual\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013101(a)(3)(A) of this title","href":"/us/usc/t42/s1395w\u2013101/a/3/A","tail":"."},{"t":"ref","text":"1"},{"t":"num","text":"1","tail":"\u202fSee References in Text note below."},{"t":"text","text":"\u202fSee References in Text note below."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/5","children":[{"t":"num","text":"(5)"},{"t":"heading","text":"Fallback prescription drug plan"},{"t":"content","children":[{"t":"p","text":"The term \u201cfallback prescription drug plan\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013111(g)(4) of this title","href":"/us/usc/t42/s1395w\u2013111/g/4","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/6","children":[{"t":"num","text":"(6)"},{"t":"heading","text":"Initial coverage limit"},{"t":"content","children":[{"t":"p","text":"The term \u201cinitial coverage limit\u201d means such limit as established under ","children":[{"t":"ref","text":"section 1395w\u2013102(b)(3) of this title","href":"/us/usc/t42/s1395w\u2013102/b/3","tail":" for a year before 2025, or, in the case of coverage that is not standard prescription drug coverage, the comparable limit (if any) established under the coverage for such year."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/7","children":[{"t":"num","text":"(7)"},{"t":"heading","text":"Insurance risk"},{"t":"content","children":[{"t":"p","text":"The term \u201cinsurance risk\u201d means, with respect to a participating pharmacy, risk of the type commonly assumed only by insurers licensed by a State and does not include payment variations designed to reflect performance-based measures of activities within the control of the pharmacy, such as formulary compliance and generic drug substitution.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/8","children":[{"t":"num","text":"(8)"},{"t":"heading","text":"MA plan"},{"t":"content","children":[{"t":"p","text":"The term \u201cMA plan\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013101(a)(3)(B) of this title","href":"/us/usc/t42/s1395w\u2013101/a/3/B","tail":"."},{"t":"text","text":"1"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/9","children":[{"t":"num","text":"(9)"},{"t":"heading","text":"MA\u2013PD plan"},{"t":"content","children":[{"t":"p","text":"The term \u201cMA\u2013PD plan\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013101(a)(3)(C) of this title","href":"/us/usc/t42/s1395w\u2013101/a/3/C","tail":"."},{"t":"text","text":"1"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/10","children":[{"t":"num","text":"(10)"},{"t":"heading","text":"Medicare Prescription Drug Account"},{"t":"content","children":[{"t":"p","text":"The term \u201cMedicare Prescription Drug Account\u201d means the Account created under ","children":[{"t":"ref","text":"section 1395w\u2013116(a) of this title","href":"/us/usc/t42/s1395w\u2013116/a","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/11","children":[{"t":"num","text":"(11)"},{"t":"heading","text":"PDP approved bid"},{"t":"content","children":[{"t":"p","text":"The term \u201cPDP approved bid\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013113(a)(6) of this title","href":"/us/usc/t42/s1395w\u2013113/a/6","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/12","children":[{"t":"num","text":"(12)"},{"t":"heading","text":"PDP region"},{"t":"content","children":[{"t":"p","text":"The term \u201cPDP region\u201d means such a region as provided under ","children":[{"t":"ref","text":"section 1395w\u2013111(a)(2) of this title","href":"/us/usc/t42/s1395w\u2013111/a/2","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/13","children":[{"t":"num","text":"(13)"},{"t":"heading","text":"PDP sponsor"},{"t":"content","children":[{"t":"p","text":"The term \u201cPDP sponsor\u201d means a nongovernmental entity that is certified under this part as meeting the requirements and standards of this part for such a sponsor.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/14","children":[{"t":"num","text":"(14)"},{"t":"heading","text":"Prescription drug plan"},{"t":"chapeau","text":"The term \u201cprescription drug plan\u201d means prescription drug coverage that is offered\u2014"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013151/a/14/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" under a policy, contract, or plan that has been approved under ","children":[{"t":"ref","text":"section 1395w\u2013111(e) of this title","href":"/us/usc/t42/s1395w\u2013111/e","tail":"; and"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s1395w\u2013151/a/14/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" by a PDP sponsor pursuant to, and in accordance with, a contract between the Secretary and the sponsor under ","children":[{"t":"ref","text":"section 1395w\u2013112(b) of this title","href":"/us/usc/t42/s1395w\u2013112/b","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/15","children":[{"t":"num","text":"(15)"},{"t":"heading","text":"Qualified prescription drug coverage"},{"t":"content","children":[{"t":"p","text":"The term \u201cqualified prescription drug coverage\u201d is defined in ","children":[{"t":"ref","text":"section 1395w\u2013102(a)(1) of this title","href":"/us/usc/t42/s1395w\u2013102/a/1","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/16","children":[{"t":"num","text":"(16)"},{"t":"heading","text":"Standard prescription drug coverage"},{"t":"content","children":[{"t":"p","text":"The term \u201cstandard prescription drug coverage\u201d is defined in ","children":[{"t":"ref","text":"section 1395w\u2013102(b) of this title","href":"/us/usc/t42/s1395w\u2013102/b","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/17","children":[{"t":"num","text":"(17)"},{"t":"heading","text":"State Pharmaceutical Assistance Program"},{"t":"content","children":[{"t":"p","text":"The term \u201cState Pharmaceutical Assistance Program\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013133(b) of this title","href":"/us/usc/t42/s1395w\u2013133/b","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/a/18","children":[{"t":"num","text":"(18)"},{"t":"heading","text":"Subsidy eligible individual"},{"t":"content","children":[{"t":"p","text":"The term \u201csubsidy eligible individual\u201d has the meaning given such term in ","children":[{"t":"ref","text":"section 1395w\u2013114(a)(3)(A) of this title","href":"/us/usc/t42/s1395w\u2013114/a/3/A","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s1395w\u2013151/b","children":[{"t":"num","text":"(b)"},{"t":"heading","text":"Application of part C provisions under this part"},{"t":"chapeau","text":"For purposes of applying provisions of part C under this part with respect to a prescription drug plan and a PDP sponsor, unless otherwise provided in this part such provisions shall be applied as if\u2014"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/b/1","children":[{"t":"num","text":"(1)"},{"t":"content","text":" any reference to an MA plan included a reference to a prescription drug plan;","tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/b/2","children":[{"t":"num","text":"(2)"},{"t":"content","text":" any reference to an MA organization or a provider-sponsored organization included a reference to a PDP sponsor;","tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/b/3","children":[{"t":"num","text":"(3)"},{"t":"content","text":" any reference to a contract under ","children":[{"t":"ref","text":"section 1395w\u201327 of this title","href":"/us/usc/t42/s1395w\u201327","tail":" included a reference to a contract under "},{"t":"ref","text":"section 1395w\u2013112(b) of this title","href":"/us/usc/t42/s1395w\u2013112/b","tail":";"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/b/4","children":[{"t":"num","text":"(4)"},{"t":"content","text":" any reference to part C included a reference to this part; and","tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s1395w\u2013151/b/5","children":[{"t":"num","text":"(5)"},{"t":"content","text":" any reference to an election period under ","children":[{"t":"ref","text":"section 1395w\u201321 of this title","href":"/us/usc/t42/s1395w\u201321","tail":" were a reference to an enrollment period under "},{"t":"ref","text":"section 1395w\u2013101 of this title","href":"/us/usc/t42/s1395w\u2013101","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"text","text":"\n"},{"t":"text","text":"\n"}]}]}