I 
115TH CONGRESS 
2D SESSION 
H. R. 5808 
To amend title XIX of the Social Security Act to require States to operate 
drug management programs for at-risk beneficiaries, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 15, 2018 
Mr. BILIRAKIS (for himself and Mr. BEN RAY LUJA´N of New Mexico) intro-
duced the following bill; which was referred to the Committee on Energy 
and Commerce 
A BILL 
To amend title XIX of the Social Security Act to require 
States to operate drug management programs for at- 
risk beneficiaries, 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 ‘‘Medicaid Pharma-
ceutical Home Act of 2018’’. 
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by a pharmacy selected under clause (i) for 
such individual in order for such controlled 
substance to be covered under the State 
plan (or waiver). 
‘‘(B) BENEFICIARY PREFERENCE.—In the 
case of an individual receiving a notice under 
paragraph (3)(A) of being identified as poten-
tially being an at-risk beneficiary described in 
such paragraph, such individual may submit, 
during the 30-day period following receipt of 
such notice, preferences for which health care 
providers and pharmacies the individual would 
prefer the State to select under subparagraph 
(A). The State shall select or change the selec-
tion of health care providers and pharmacies 
under subparagraph (A) for the individuals 
based on such preferences, except that in the 
case that State determines that such selection 
(or change of selection) of a health care pro-
vider or pharmacy under subparagraph (A) is 
contributing or would contribute to prescription 
drug abuse or drug diversion by the individual, 
the State may select or change the selection of 
health care provider or pharmacy for the indi-
vidual without regard to the preferences of the 
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individual described in this subparagraph. If the 
State selects or changes the selection pursuant 
to the preceding sentence without regard to the 
preferences of the individual, the State shall 
provide the individual with at least 30 days 
written notice of the selection or change of se-
lection and a rationale for the selection or 
change. 
‘‘(C) TREATMENT
OF
PHARMACY
WITH 
MULTIPLE LOCATIONS.—For purposes of sub-
paragraph (A)(i), in the case of a pharmacy 
that has multiple locations that share real-time 
electronic prescription data and the same chain 
identification number, all such locations of the 
pharmacy shall collectively be treated as one 
pharmacy. 
‘‘(D) TREATMENT OF EXISTING FFS DRUG 
MANAGEMENT PROGRAMS.—In the case of a pa-
tient review and restriction program (as identi-
fied in the annual report submitted to the Sec-
retary under section 1927(g)(3)(D)) operated 
by a State pursuant to section 1915(a)(2) be-
fore the date of the enactment of this section, 
such program shall be treated as a qualified 
drug management program. 
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‘‘(E) REASONABLE ACCESS.—The program 
shall ensure, including through waiver of ele-
ments of the program (including under sub-
paragraph (A)(ii)), reasonable access to health 
care (including access to health care providers 
and pharmacies with respect to prescription 
drugs described in subparagraph (A)) in the 
case of individuals with multiple residences, in 
the case of natural disasters and similar situa-
tions, and in the case of the provision of emer-
gency services (as defined for purposes of sec-
tion 1860D–4(c)(5)(D)(ii)(II)). 
‘‘(3) NOTIFICATION
TO
IDENTIFIED
INDIVID-
UALS.—Under the program, the State provides each 
individual who is identified under paragraph (1), 
prior to enrolling such individual under the program, 
at least one notification of each of the following: 
‘‘(A) Notice that the State has identified 
the individual as potentially being an at-risk 
beneficiary for abuse or misuse of a controlled 
substance. 
‘‘(B) The name, address, and contact in-
formation of each health care provider and 
pharmacy that may be selected for the indi-
vidual under paragraph (2)(A). 
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‘‘(C) Information describing all State and 
Federal public health resources that are de-
signed to address such abuse or misuse to 
which the individual has access, including men-
tal health services and other counseling serv-
ices. 
‘‘(D) Notice of, and information about, the 
right of the individual to— 
‘‘(i) submit preferences of the indi-
vidual for health care providers and phar-
macies to be selected under paragraph 
(2)(A), including as described in paragraph 
(2)(B); 
‘‘(ii) appeal under paragraph (4)— 
‘‘(I) such identification described 
in subparagraph (A); and 
‘‘(II) the selection of health care 
providers and pharmacies under para-
graph (2)(A). 
‘‘(E) An explanation of the meaning and 
consequences of the identification of the indi-
vidual as potentially being an at-risk beneficiary 
for abuse or misuse of a controlled substance, 
including an explanation of the program. 
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‘‘(F) Information, including a contact list 
and clear instructions, that explain how the in-
dividual can contact the appropriate entities ad-
ministering the program in order to submit 
preferences described in paragraph (2)(B) and 
any other communications relating to the pro-
gram. 
‘‘(4) APPEALS PROCESS.—Under the program, 
the State provides for an appeals process under 
which, with respect to an individual identified under 
paragraph (1)— 
‘‘(A) such individual may appeal— 
‘‘(i) such identification; and 
‘‘(ii) the selection of a health care pro-
vider or pharmacy under paragraph (2)(A); 
‘‘(B) in the case of an appeal described in 
subparagraph (A)(ii), the State shall accommo-
date the health care provider or pharmacy pre-
ferred by the individual for selection for pur-
poses of paragraph (2)(A), unless the State de-
termines that a change to the selection of 
health care provider or pharmacy under such 
paragraph is contributing or would contribute 
to prescription drug abuse or drug diversion by 
the individual; 
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‘‘(C) such individual is provided a period of 
not less than 30 days following the date of re-
ceipt of the notice described in paragraph (3) to 
submit such appeal; and 
‘‘(D) the State must make a determination 
with respect to an appeal described in subpara-
graph (A), and notify the individual of such de-
termination, prior to enrollment of such indi-
vidual in the program. 
‘‘(5) ENROLLMENT.—Under the program, the 
State initially enrolls individuals who are identified 
under paragraph (1) in the program for a 12-month 
period— 
‘‘(A) in the case of such an individual who 
does not submit an appeal under paragraph (4) 
within the period applied by the State pursuant 
to subparagraph (C) of such paragraph, begin-
ning on the day after the last day of such pe-
riod; and 
‘‘(B) in the case of such an individual who 
does submit an appeal under paragraph (4) 
within the period applied by the State pursuant 
to subparagraph (C) of such paragraph but 
such appeal is denied, beginning not later than 
30 days after the date of such denial. 
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