I 
115TH CONGRESS 
2D SESSION 
H. R. 7001 
To amend title XVIII of the Social Security Act to provide for a combined 
Medicare part B and D drug out-of-pocket costs limitation. 
IN THE HOUSE OF REPRESENTATIVES 
SEPTEMBER 28, 2018 
Mr. O’HALLERAN introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committee 
on Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for a combined Medicare part B and D drug out-of- 
pocket costs limitation. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Capped Allowable Pay-
ments from Seniors for Prescriptions Act’’ or the ‘‘CAPS 
for Prescriptions Act’’. 
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SEC. 2. LIMITING MEDICARE PART B AND D DRUG OUT-OF- 
POCKET COSTS. 
(a) MEDICARE COMBINED PART B AND D DRUG 
OOP CATASTROPHIC LIMIT AND PART D SUBSIDIES.— 
Part D of title XVIII of the Social Security Act is amend-
ed by inserting after section 1860D–14A (42 U.S.C. 
1395w–114a) the following new section: 
‘‘SEC. 1860D–14B. MEDICARE DRUG OUT-OF-POCKET LIMIT 
SUBSIDIES. 
‘‘(a) IN GENERAL.—For plan year 2021 and each 
subsequent plan year, in the case of a part D eligible indi-
vidual enrolled in a prescription drug plan under this part 
for such year— 
‘‘(1) if during such year such individual be-
comes a catastrophic limit subsidy eligible individual, 
such individual is entitled to the elimination of any 
beneficiary coinsurance described in section 1860D– 
2(b)(2) for covered part D drugs furnished to such 
individual during the remainder of such year; and 
‘‘(2) the Secretary shall provide for payment to 
the PDP sponsor that offers such prescription drug 
plan of a catastrophic limit coverage subsidy (cal-
culated under subsection (b)) in accordance with this 
section for such individual and remainder of such 
year. 
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‘‘(b) CATASTROPHIC
LIMIT
COVERAGE
SUBSIDY 
AMOUNT.—For purposes of this section, a catastrophic 
limit coverage subsidy, with respect to a catastrophic limit 
subsidy eligible individual enrolled for coverage under this 
part in a prescription drug plan for a plan year, shall be 
calculated as an amount (or amounts) equal to any cost- 
sharing amount that— 
‘‘(1) would otherwise apply without application 
of subsection (a)(1) to such individual under such 
coverage for covered part D drugs furnished to such 
individuals during such year; but 
‘‘(2) does not apply to such individual with ap-
plication of subsection (a)(1). 
Such subsidy may be paid in such manner and at such 
times as specified by the Secretary. 
‘‘(c) CATASTROPHIC LIMIT SUBSIDY ELIGIBLE INDI-
VIDUAL.—For purposes of this section, the term ‘cata-
strophic limit subsidy eligible individual’ means, with re-
spect to a prescription drug plan under this part and plan 
year, a part D eligible individual enrolled in such plan for 
such year who has incurred out-of-pocket costs described 
in subsection (e) for eligible Medicare drugs furnished to 
such individual during such year above the OOP drug cat-
astrophic limit specified in subsection (d) for such year. 
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‘‘(d) OOP DRUG CATASTROPHIC LIMIT.—For pur-
poses of this part, the OOP drug catastrophic limit speci-
fied in this subsection is— 
‘‘(1) for plan year 2021, $2,600; and 
‘‘(2) for a subsequent plan year, the dollar 
amount applied under this subsection for the pre-
vious plan year, increased by the annual percentage 
increase in average per capita aggregate expendi-
tures for covered part D drugs in the United States 
for part D eligible individuals, as determined by the 
Secretary for the 12-month period ending in July of 
the previous year using such methods as the Sec-
retary shall specify. 
‘‘(e) OUT-OF-POCKET COSTS DESCRIBED.— 
‘‘(1) IN GENERAL.—For purposes of this sec-
tion— 
‘‘(A) incurred out-of-pocket costs shall only 
include— 
‘‘(i) costs incurred with respect to cov-
ered part D drugs for the annual deduct-
ible described in paragraph (1), for cost- 
sharing described in paragraph (2), and 
for amounts for which benefits are not pro-
vided because of the application of the ini-
tial coverage limit described in paragraph 
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