I 
113TH CONGRESS 
1ST SESSION H. R. 2960 
To amend title XVIII of the Social Security Act to require sponsors of 
Medicare prescription drug plans to implement procedures to prevent 
fraud and abuse, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
AUGUST 1, 2013 
Mr. PALLONE introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committees on 
Ways and Means and the Judiciary, for a period to be subsequently de-
termined 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 require 
sponsors of Medicare prescription drug plans to imple-
ment procedures to prevent fraud and abuse, and for 
other purposes. 
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 ‘‘Medicare Prescription 
Drug Integrity Act of 2013’’. 
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SEC. 2. PREVENTION OF FRAUD AND ABUSE IN MEDICARE 
PRESCRIPTION DRUG PLANS. 
(a) PROCEDURES FOR PDP SPONSORS TO IDENTIFY 
FRAUD AND ABUSE.—Section 1860D–4(c) of the Social 
Security Act (42 U.S.C. 1395w–104(c)) is amended— 
(1) in paragraph (1)(D)— 
(A) by inserting ‘‘, designed to’’ after 
‘‘program’’; and 
(B) by inserting ‘‘, that includes the proce-
dures described in paragraph (4)’’ after 
‘‘waste’’; and 
(2) by adding at the end the following: 
‘‘(4) PROCEDURES
TO
PREVENT
FRAUD
AND 
ABUSE.— 
‘‘(A) PDP 
SPONSOR
PROCEDURES.—A 
PDP sponsor shall have in place procedures de-
signed to— 
‘‘(i) identify an individual that has ob-
tained coverage for a covered part D drug 
at a frequency or amount not medically 
necessary, as determined in accordance 
with utilization guidelines established by 
the Secretary; 
‘‘(ii) subject to procedures developed 
by the Secretary, limit coverage for some 
or all classes of covered part D drugs for 
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an individual identified under clause (i) to 
drugs prescribed by one or more des-
ignated prescribers or dispensed by one or 
more designated dispensers, or both, for a 
reasonable period of time following the 
date the individual is notified of such iden-
tification; 
‘‘(iii) provide to the Secretary the 
name, and other information that the Sec-
retary may require, of individuals identi-
fied pursuant to clause (i); 
‘‘(iv) as directed by the Secretary, 
limit coverage for some or all classes of 
covered part D drugs for an individual 
identified pursuant to clause (i) by a PDP 
sponsor with whom such individual was 
previously enrolled; and 
‘‘(v) deny payment of a claim for a 
controlled substance in schedule II or III 
as established under Controlled Substances 
Act unless the PDP sponsor has verified at 
point-of-sale that the prescriber and dis-
penser are authorized by the Administrator 
of the Drug Enforcement Administration 
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to prescribe or dispense such controlled 
substances. 
‘‘(B) AUTHORIZATION
FOR
THE
SEC-
RETARY
TO
SHARE
INFORMATION.—The Sec-
retary may share information with respect to an 
individual provided under subparagraph (A)(iii) 
with a PDP sponsor enrolling such individual.’’. 
(b) DUAL ELIGIBLES.—Section 1860D–1(b)(3)(D) of 
the Social Security Act (42 U.S.C. 1395w–101(b)(3)(D)) 
is amended by inserting ‘‘, subject to such limits as the 
Secretary may establish for individuals identified pursuant 
to section 1860D–4(c)(4)(A)(i)’’ after ‘‘the Secretary’’. 
(c) EXCLUSION AND DENIAL OF PAYMENT FOR INAP-
PROPRIATE PRESCRIBING AND DISPENSING.— 
(1) EXCLUSION
FOR
INAPPROPRIATE
PRE-
SCRIBING OR DISPENSING.—Section 1128(b) of the 
Social Security Act (42 U.S.C. 1320a–7(b)) is 
amended by adding at the end the following: 
‘‘(17) INAPPROPRIATE
PRESCRIBING
OR
DIS-
PENSING.—Any individual or entity that the Sec-
retary determines has prescribed or dispensed under 
title XVIII— 
‘‘(A) a covered part D drug to an indi-
vidual under a prescription drug plan or a MA- 
PD plan, as such terms are defined for pur-
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poses of part D of such title, that could not 
have been prescribed or dispensed to the indi-
vidual on the date of such prescribing or dis-
pensing; or 
‘‘(B) any drug under such title at a fre-
quency or amount that— 
‘‘(i) represents a practice or pattern 
of abusive prescribing or dispensing; or 
‘‘(ii) presents a risk to enrollee health 
or safety.’’. 
(2) DENIAL OF PAYMENT FOR INAPPROPRIATE 
PRESCRIBING
OR
DISPENSING.—Section 1860D– 
2(e)(3) of the Social Security Act (42 U.S.C. 
1395w–102(e)(3)) is amended— 
(A) in subparagraph (A), by striking ‘‘; 
or’’ and inserting a semicolon; 
(B) in subparagraph (B), by striking the 
period at the end and inserting ‘‘; or’’; 
(C) by inserting after subparagraph (B) 
the following: 
‘‘(C) which is prescribed or dispensed by 
an individual or entity that the Secretary deter-
mines, subject to such review, redetermination, 
and appeal as the Secretary provides, has pre-
scribed or dispensed to an individual under a 
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prescription drug plan or a MA–PD plan a cov-
ered part D drug— 
‘‘(i) that could not have been pre-
scribed or dispensed to the individual on 
the date of such prescribing or dispensing; 
or 
‘‘(ii) at a frequency or amount that 
presents a risk to the health or safety of 
an enrollee or that represents a practice or 
pattern of abusive prescribing or dis-
pensing.’’; and 
(D) by adding at the end the following: 
‘‘The exclusion of a prescriber or dispenser 
under subparagraph (C) shall be for such pe-
riod of time as the Secretary shall specify.’’ 
(d) REGISTRATION OF AUTHORIZATION FOR INDIVID-
UALS TO PRESCRIBE AND DISPENSE CONTROLLED SUB-
STANCES.—Section 303 of the Controlled Substances Act 
(21 U.S.C. 823) is amended by adding at the end the fol-
lowing: 
‘‘(i) UNIQUE HEALTH IDENTIFIERS FOR MEMBERS 
OF GROUP PRACTICES.— 
‘‘(1) IN
GENERAL.—The Attorney General 
shall— 
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‘‘(A) compile and maintain a list of the 
unique health identifiers of prescribers and dis-
pensers that are members of a group practice 
registered under this section and have authority 
to prescribe or dispense controlled substances in 
schedules II and III; and 
‘‘(B) make the list compiled under sub-
paragraph (A) available to all PDP sponsors. 
‘‘(2) DEFINITIONS.—In this section: 
‘‘(A) GROUP PRACTICE.—The term ‘group 
practice’ has the meaning given such term in 
section 1877(h)(4) of the Social Security Act. 
‘‘(B) UNIQUE HEALTH IDENTIFIER.—The 
term ‘unique health identifier’ has the meaning 
given such term in section 1173(b) of the Social 
Security Act. 
‘‘(C) PDP SPONSOR.—The term ‘PDP 
sponsor’ has the meaning given such term in 
section 1860D–41(a)(13) of the Social Security 
Act.’’. 
(e) USE OF RECOVERY AUDIT CONTRACTOR RECOV-
ERIES
TO
PREVENT
FRAUD
AND
WASTE.—Section 
1893(h)(1)(C) of the Social Security Act (42 U.S.C. 
1395ddd(h)(1)(C)) is amended— 
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(1) by striking ‘‘the Secretary shall retain’’ and 
inserting ‘‘the Secretary— 
‘‘(i) shall retain’’; 
(2) in clause (i), as added by paragraph (1)— 
(A) by inserting ‘‘, in addition to any other 
funds that may be available,’’ after ‘‘available’’; 
and 
(B) by striking the period at the end and 
inserting ‘‘; and’’; and 
(3) by adding at the end the following: 
‘‘(ii) may retain an additional portion 
of the amounts recovered (not to exceed 25 
percent of such amounts recovered) which 
shall be available, in addition to any other 
funds that may be available, to such pro-
gram management account until expended 
for purposes of carrying out the amend-
ments made by the Medicare Prescription 
Drug Integrity Act of 2013.’’. 
(f) IMPLEMENTATION.—The Secretary of Health and 
Human Services may implement the amendments made by 
subsections (a), (b), and (c)(2) by regulations, guidance, 
or otherwise. 
(g) EFFECTIVE DATE.— 
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(1) IN GENERAL.—Except as provided in para-
graph (2), the amendments made by this section 
shall take effect on the date of the enactment of this 
Act. 
(2) DELAYED EFFECTIVE DATE FOR CERTAIN 
PROVISIONS.—The amendments made by subsection 
(a) shall apply with respect to plan years beginning 
after the date that is 8 months after the date of the 
enactment of this Act, except that subparagraph 
(A)(v) of section 1860D–4(c)(4) of the Social Secu-
rity Act, as added by subsection (a)(2), shall apply 
with respect to plan years beginning after the date 
that is 6 months after the date on which the Sec-
retary of Health and Human Services determines 
PDP sponsors, as defined in section 1860D– 
41(a)(13) of the Social Security Act (42 U.S.C. 
1395w–151(a)(13)), have access at the point-of-sale 
to the information necessary to determine valid pre-
scribing and dispensing authority. 
Æ 
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