‘‘(A) Access to covered outpatient drugs,
including access through pharmacy networks.
‘‘(B) How any formulary used by the eligi-
ble entity functions.
‘‘(C) Grievance and appeals procedures.
‘‘(2) DISCLOSURE UPON REQUEST OF GENERAL
COVERAGE, UTILIZATION, AND GRIEVANCE INFORMA-
TION.—Upon request of an eligible beneficiary, the
eligible entity shall provide the information described
in section 1852(c)(2) (other than subparagraph (D))
to such beneficiary.
‘‘(3) RESPONSE TO BENEFICIARY QUESTIONS.—
Each eligible entity offering prescription drug cov-
erage under this part shall have a mechanism for
providing specific information to enrollees upon re-
quest. The entity shall make available, through an
Internet website and in writing upon request, infor-
mation on specific changes in its formulary.
‘‘(c) ACCESS TO COVERED BENEFITS.—
‘‘(1) ENSURING PHARMACY ACCESS.—
‘‘(A) IN
GENERAL.—Each eligible entity
with a contract under this part shall permit any
pharmacy located in the area covered by such
contract to participate in the pharmacy network
of the eligible entity if the pharmacy agrees to
accept such operating terms as the eligible enti-
ty may specify, including any fee schedule, re-
quirements relating to covered expenses, and
quality standards relating to the provision of
prescription drug coverage.
‘‘(B) CONSTRUCTION.—Nothing in this
paragraph shall be construed as requiring a
pharmacy to participate in a pharmacy network
of an eligible entity with a contract under this
part to participate in any other coverage pro-
gram of the eligible entity.
‘‘(2) ACCESS TO NEGOTIATED PRICES FOR PRE-
SCRIPTION
DRUGS.—For requirements relating to
the access of an eligible beneficiary to negotiated
prices (including applicable discounts), see section
1860F(a).
‘‘(3) REQUIREMENTS
ON
DEVELOPMENT
AND
APPLICATION OF FORMULARIES.—Insofar as an eli-
gible entity with a contract under this part uses a
formulary, the following requirements must be met:
‘‘(A) FORMULARY COMMITTEE.—The eligi-
ble entity must establish a pharmaceutical and
therapeutic committee that develops the for-
mulary. Such committee shall include at least 1
physician and at least 1 pharmacist.
‘‘(B) INCLUSION OF DRUGS IN ALL THERA-
PEUTIC CATEGORIES.—The formulary must in-
clude drugs within all therapeutic categories
and classes of covered outpatient drugs (al-
though not necessarily for all drugs within such
categories and classes).
‘‘(C) APPEALS AND EXCEPTIONS TO APPLI-
CATION.—The entity must have, as part of the
appeals process under subsection (f)(2), a proc-
ess for appeals for denials of coverage based on
such application of the formulary.
‘‘(d) COST AND UTILIZATION MANAGEMENT; QUAL-
ITY ASSURANCE; MEDICATION THERAPY MANAGEMENT
PROGRAM.—
‘‘(1) IN GENERAL.—For purposes of providing
access to negotiated benefits under section 1860F(a)
and the catastrophic benefit described in section
1860F(b), the eligible entity shall have in place—
‘‘(A) an effective cost and drug utilization
management program, including appropriate in-
centives to use generic drugs, when appropriate;
‘‘(B) quality assurance measures and sys-
tems to reduce medical errors and adverse drug
interactions, including a medication therapy
management program described in paragraph
(2); and
‘‘(C) a program to control fraud, abuse,
and waste.
‘‘(2) MEDICATION THERAPY MANAGEMENT PRO-
GRAM.—
‘‘(A) IN GENERAL.—A medication therapy
management program described in this para-
graph is a program of drug therapy manage-
ment and medication administration provided
by a community-based pharmacy that is de-
signed to ensure that prescription drugs made
available under this part are appropriately used
to achieve therapeutic goals and reduce the risk
of adverse events, including adverse drug inter-
actions.
‘‘(B) ELEMENTS.—Such program shall
include—
‘‘(i) 
enhanced 
beneficiary 
under-
standing of such appropriate use through
beneficiary 
education, 
counseling, 
and
other appropriate means; and
‘‘(ii) increased beneficiary adherence
with 
prescription 
medication 
regimens
through medication refill reminders, special
packaging, and other appropriate means.
‘‘(C) DEVELOPMENT OF PROGRAM IN CO-
OPERATION
WITH
LICENSED
PHARMACISTS.—
The program shall be developed in cooperation
with licensed pharmacists and physicians.
‘‘(D) 
CONSIDERATIONS
IN
PHARMACY
FEES.—An eligible entity with a contract under
this part shall establish fees for pharmacists,
pharmacies, and others providing services under
the medication therapy management program
that take into account the resources and time
used in implementing the program.
‘‘(3) TREATMENT OF ACCREDITATION.—Section
1852(e)(4) (relating to treatment of accreditation)
shall apply to prescription drug coverage provided
under this part with respect to the following require-
ments, in the same manner as they apply to
Medicare+Choice plans under part C with respect to
the requirements described in a clause of section
1852(e)(4)(B):
‘‘(A) Subsection (c)(1) (relating to access
to covered benefits).
‘‘(B) Subsection (g) (relating to confiden-
tiality and accuracy of enrollee records).
‘‘(e) GRIEVANCE MECHANISM.—Each eligible entity
shall provide meaningful procedures for hearing and re-
solving grievances between the organization (including any
entity or individual through which the eligible entity pro-
vides covered benefits) and eligible beneficiaries enrolled
with the entity under this part in accordance with section
1852(f).
‘‘(f) COVERAGE
DETERMINATIONS, RECONSIDER-
ATIONS, AND APPEALS.—
‘‘(1) IN
GENERAL.—An eligible entity shall
meet the requirements of section 1852(g) with re-
spect to covered benefits under the prescription drug
coverage it offers under this part in the same man-
ner 
as 
such 
requirements 
apply 
to 
a
Medicare+Choice organization with respect to bene-
fits it offers under a Medicare+Choice plan under
part C.
‘‘(2) APPEALS
OF
FORMULARY
DETERMINA-
TIONS.—Under the appeals process under paragraph
(1) an individual who is enrolled with an eligible en-
tity with a contract under this part for prescription
drug coverage may appeal any denial of coverage of
a prescription drug to obtain coverage for a medi-
cally necessary covered outpatient drug that is not
on the formulary of the eligible entity (established