prescription drug plans that a PDP sponsor may offer, 
at the discretion of the PDP sponsor, in a PDP region 
under part D of title XVIII of the Social Security Act (42 
U.S.C. 1395w–101 et seq.). 
SEC. 132. ALLOWING CERTAIN ENROLLEES OF PRESCRIP-
TION DRUG PLANS AND MA–PD PLANS UNDER 
MEDICARE PROGRAM TO SPREAD OUT COST- 
SHARING UNDER CERTAIN CIRCUMSTANCES. 
(a) STANDARD PRESCRIPTION DRUG COVERAGE.— 
Section 1860D–2(b)(2) of the Social Security Act (42 
U.S.C. 1395w–102(b)(2)), as amended by section 121, is 
further amended— 
(1) in subparagraph (A), by striking ‘‘Subject 
to subparagraphs (C) and (D)’’ and inserting ‘‘Sub-
ject to subparagraphs (C), (D), and (E)’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(E) 
ENROLLEE
OPTION
REGARDING 
SPREADING COST-SHARING.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall establish by regulation a process 
under which, with respect to plan year 
2022 and subsequent plan years, a pre-
scription drug plan or an MA–PD plan 
shall, in the case of a part D eligible indi-
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vidual enrolled with such plan for such 
plan year with respect to whom the plan 
projects that the dispensing of a covered 
part D drug to such individual will result 
in the individual incurring costs within a 
30-day period that are equal to a signifi-
cant percentage (as specified by the Sec-
retary pursuant to such regulation) of the 
annual out-of-pocket threshold specified in 
paragraph (4)(B) for such plan year, pro-
vide such individual with the option to 
make the coinsurance payment required 
under subparagraph (A) for such costs in 
the form of equal monthly installments 
over the remainder of such plan year. 
‘‘(ii) SIGNIFICANT PERCENTAGE LIMI-
TATIONS.—In specifying a significant per-
centage pursuant to the regulation estab-
lished by the Secretary under clause (i), 
the Secretary may not specify a percentage 
that is less than 30 percent or greater 
than 100 percent.’’. 
(b) 
ALTERNATIVE
PRESCRIPTION
DRUG
COV-
ERAGE.—Section 1860D–2(c) of the Social Security Act 
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(42 U.S.C. 1395w–102(c)) is amended by adding at the 
end the following new paragraph: 
‘‘(4) SAME
ENROLLEE
OPTION
REGARDING 
SPREADING
COST-SHARING.—For plan year 2022 
and subsequent plan years, the coverage provides the 
enrollee option regarding spreading cost-sharing de-
scribed 
in 
and 
required 
under 
subsection 
(b)(2)(E).’’. 
SEC. 133. ESTABLISHING A MONTHLY CAP ON BENEFICIARY 
INCURRED COSTS FOR INSULIN PRODUCTS 
AND 
SUPPLIES 
UNDER 
A 
PRESCRIPTION 
DRUG PLAN OR MA–PD PLAN. 
(a) IN GENERAL.—Section 1860D–2 of the Social 
Security Act (42 U.S.C. 1395w–102), as amended by sec-
tions 121 and 133, is further amended— 
(1) in subsection (b)(2)— 
(A) in subparagraph (A), by striking ‘‘and 
(E)’’ and inserting ‘‘(E), and (F)’’; 
(B) in subparagraph (B), by striking ‘‘and 
(D)’’ and inserting ‘‘(D), and (F)’’; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F) CAP ON INCURRED COSTS FOR INSU-
LIN PRODUCTS AND SUPPLIES.— 
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‘‘(i) IN GENERAL.—The coverage pro-
vides benefits, for costs above the annual 
deductible specified in paragraph (1) and 
up to the annual out-of-pocket threshold 
described in paragraph (4)(B) and with re-
spect to a month (beginning with January 
of 2022), with cost sharing that is equal to 
$0 for a specified covered part D drug (as 
defined in clause (iii)) furnished to an indi-
vidual who has incurred costs during such 
month with respect to specified covered 
part D drugs equal to— 
‘‘(I) for months occurring in 
2022, $50; or 
‘‘(II) for months occurring in a 
subsequent year, the amount applica-
ble under this clause for months oc-
curring in the year preceding such 
subsequent year, increased by the an-
nual percentage increase specified in 
paragraph (6) for such subsequent 
year and rounded to the nearest dol-
lar. 
‘‘(ii) APPLICATION.—The provisions 
of clauses (i) through (iii) of paragraph 
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(4)(C) shall apply with respect to the de-
termination of the incurred costs for speci-
fied covered part D drugs for purposes of 
clause (i) in the same manner as such pro-
visions apply with respect to the deter-
mination of incurred costs for covered part 
D drugs for purposes of paragraph (4)(A). 
‘‘(iii) SPECIFIED
COVERED
PART
D 
DRUG.—For purposes of this subpara-
graph, the term ‘specified covered part D 
drug’ means a covered part D drug that 
is— 
‘‘(I) insulin; or 
‘‘(II) a medical supply associated 
with the injection of insulin (as de-
fined in regulations of the Secretary 
promulgated pursuant to subsection 
(e)(1)(B)).’’; and 
(2) in subsection (c), by adding at the end the 
following new paragraph: 
‘‘(5) SAME PROTECTION WITH RESPECT TO EX-
PENDITURES FOR INSULIN AND CERTAIN MEDICAL 
SUPPLIES.—The coverage provides the coverage re-
quired under subsection (b)(2)(F).’’. 
(b) CONFORMING AMENDMENTS.— 
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(1) IN GENERAL.—Section 1860D–14(a)(1)(D) 
of the Social Security Act (42 U.S.C. 1395w– 
114(a)(1)(D)), as amended by section 121, is fur-
ther amended— 
(A) in clause (ii), by striking ‘‘section 
1860D–2(b)(2)’’ and inserting ‘‘section 1860D– 
2(b)(2)(A)’’; and 
(B) in clause (iii), by striking ‘‘section 
1860D–2(b)(2)’’ and inserting ‘‘section 1860D– 
2(b)(2)(A)’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply with respect to plan 
year 2022 and each subsequent plan year. 
SEC. 134. GROWTH RATE OF MEDICARE PART D OUT-OF- 
POCKET COST THRESHOLD. 
(a) PROVIDING MEDICARE PART D BENEFICIARIES 
WITH
CERTAIN
2020 OFFSET
PAYMENTS.—Section 
1860D–2(b)(4) of the Social Security Act (42 U.S.C. 
1395w–102(b)(4)) is amended by adding at the end the 
following new subparagraph: 
‘‘(F) 2020 OFFSET PAYMENTS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(iv), the Secretary shall provide for pay-
ment from the Medicare Prescription Drug 
Account as follows: 
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‘‘(ii) DEFINITIONS.—For purposes of 
this subparagraph: 
‘‘(I) SPECIFIED
INDIVIDUAL.— 
The term ‘specified individual’ means 
an individual who— 
‘‘(aa) is enrolled in a pre-
scription drug plan or an MA– 
PD plan; 
‘‘(bb) is not enrolled in a 
qualified retiree prescription drug 
plan; and 
‘‘(cc) is not entitled to an in-
come-related subsidy under sec-
tion 1860D–14(a). 
‘‘(II) TARGET
THRESHOLD
FOR 
2020.—The term ‘target threshold for 
2020’ means the annual out-of-pocket 
threshold that would have been ap-
plied under subparagraph (B)(i) for 
2020 if such threshold had been de-
termined in accordance with subclause 
(IV) of such subparagraph instead of 
subclause (V) of such subparagraph. 
‘‘(iii) NOTIFICATION.—In the case of 
any specified individual who during 2020 
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has incurred costs for covered part D 
drugs so that the individual has exceeded 
the target threshold for 2020, the Sec-
retary shall, not later than September 30, 
2021, provide to such individual a notifica-
tion informing such individual of such indi-
vidual’s right to a payment described in 
clause (i) and the estimated timing of such 
payment. 
‘‘(iv) CLARIFICATION.—The Secretary 
shall provide only 1 payment under this 
subparagraph with respect to any indi-
vidual. 
‘‘(v) 
IMPLEMENTATION.—The 
Sec-
retary may implement this subparagraph 
by program instruction or otherwise.’’. 
(b) REDUCED GROWTH RATE FOR 2021 OF MEDI-
CARE PART D OUT-OF-POCKET COST THRESHOLD.—Sec-
tion 1860D–2(b)(4)(B)(i) of the Social Security Act (42 
U.S.C. 1395w–102(b)(4)(B)(i)) is amended— 
(1) in subclause (V), by striking at the end 
‘‘or’’; 
(2) by redesignating subclause (VI) as sub-
clause (VIII); and 
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(3) by inserting after subclause (V) the fol-
lowing new subclauses: 
‘‘(VI) for 2021, is equal to the 
amount that would have been applied 
under this subparagraph for 2020 if 
such amount had been determined in 
accordance with subclause (IV) in-
stead of subclause (V), increased by 
the lesser of— 
‘‘(aa) the annual percentage 
increase described in paragraph 
(7) for 2021, plus 2 percentage 
points; or 
‘‘(bb) the annual percentage 
increase described in paragraph 
(6) for 2021; 
‘‘(VII) for 2022, is equal to the 
amount that would have been applied 
under this subparagraph for 2022 if 
the amendments made by section 
1101(d)(1) of the Health Care and 
Education Reconciliation Act of 2010 
and by section 134 of the Lower 
Costs, More Cures Act of 2021 had 
not been enacted; or’’. 
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TITLE II—MEDICAID 
SEC. 201. MEDICAID PHARMACY AND THERAPEUTICS COM-
MITTEE IMPROVEMENTS. 
(a) IN GENERAL.—Subparagraph (A) of section 
1927(d)(4) of the Social Security Act (42 U.S.C. 1396r– 
8(d)(4)) is amended to read as follows: 
‘‘(A)(i) The formulary is developed and re-
viewed by a pharmacy and therapeutics com-
mittee consisting of physicians, pharmacists, 
and other appropriate individuals appointed by 
the Governor of the State. 
‘‘(ii) Subject to clause (vi), the State estab-
lishes and implements a conflict of interest pol-
icy for the pharmacy and therapeutics com-
mittee that— 
‘‘(I) is publicly accessible; 
‘‘(II) requires all committee members 
to complete, on at least an annual basis, a 
disclosure of relationships, associations, 
and financial dealings that may affect their 
independence of judgement in committee 
matters; and 
‘‘(III) contains clear processes, such 
as recusal from voting or discussion, for 
those members who report a conflict of in-
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terest, along with appropriate processes to 
address any instance where a member fails 
to report a conflict of interest. 
‘‘(iii) The membership of the pharmacy 
and therapeutics committee— 
‘‘(I) includes at least 1 actively prac-
ticing physician and at least 1 actively 
practicing pharmacist, each of whom— 
‘‘(aa) is independent and free of 
conflict with respect to manufacturers 
and Medicaid participating plans or 
subcontractors, including pharmacy 
benefit managers; and 
‘‘(bb) has expertise in the care of 
1 or more Medicaid-specific popu-
lations such as elderly or disabled in-
dividuals, children with complex med-
ical needs, or low-income individuals 
with chronic illnesses; and 
‘‘(II) is made publicly available. 
‘‘(iv) At the option of the State, the 
State’s drug use review board established under 
subsection (g)(3) may serve as the pharmacy 
and therapeutics committee provided the State 
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ensures that such board meets the requirements 
of clauses (ii) and (iii). 
‘‘(v) The State reviews and has final ap-
proval of the formulary established by the phar-
macy and therapeutics committee. 
‘‘(vi) If the Secretary determines it appro-
priate or necessary based on the findings and 
recommendations of the Comptroller General of 
the United States in the report submitted to 
Congress under section 203 of the Lower Costs, 
More Cures Act of 2021, the Secretary shall 
issue guidance that States must follow for es-
tablishing conflict of interest policies for the 
pharmacy and therapeutics committee in ac-
cordance with the requirements of clause (ii), 
including appropriate standards and require-
ments for identifying, addressing, and reporting 
on conflicts of interest.’’. 
(b) APPLICATION TO MEDICAID MANAGED CARE OR-
GANIZATIONS.—Clause (xiii) of section 1903(m)(2)(A) of 
the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) is 
amended— 
(1) by striking ‘‘and (III)’’ and inserting 
‘‘(III)’’; 
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