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to frequently abused drugs) in the 
case of individuals with multiple resi-
dences and in the case of natural dis-
asters and similar emergency situa-
tions. 
‘‘(iii) BENEFICIARY PREFERENCES.— 
If an at-risk beneficiary for prescription 
drug abuse submits preferences for which 
in-network prescribers and pharmacies the 
beneficiary would prefer the PDP sponsor 
select in response to a notice under sub-
paragraph (B), the PDP sponsor shall— 
‘‘(I) review such preferences; 
‘‘(II) select or change the selec-
tion of prescribers and pharmacies for 
the beneficiary based on such pref-
erences; and 
‘‘(III) inform the beneficiary of 
such selection or change of selection. 
‘‘(iv) EXCEPTION REGARDING BENE-
FICIARY PREFERENCES.—In the case that 
the PDP sponsor determines that a change 
to the selection of prescriber or pharmacy 
under clause (iii)(II) by the PDP sponsor 
is contributing or would contribute to pre-
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scription drug abuse or drug diversion by 
the beneficiary, the PDP sponsor may 
change the selection of prescriber or phar-
macy for the beneficiary without regard to 
the preferences of the beneficiary described 
in clause (iii). 
‘‘(v) CONFIRMATION.—Before select-
ing a prescriber (or prescribers) or phar-
macy (or pharmacies) under this subpara-
graph, a PDP sponsor must request and 
receive confirmation from such a prescriber 
or pharmacy acknowledging and accepting 
that the beneficiary involved is in the drug 
management program for at-risk bene-
ficiaries. 
‘‘(E) TERMINATIONS AND APPEALS.—The 
identification of an individual as an at-risk ben-
eficiary for prescription drug abuse under this 
paragraph, a coverage determination made 
under a drug management program for at-risk 
beneficiaries, and the selection of prescriber or 
pharmacy under subparagraph (D) with respect 
to such individual shall be subject to reconsider-
ation and appeal under subsection (h) and the 
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option of an automatic escalation to external re-
view to the extent provided by the Secretary. 
‘‘(F) TERMINATION OF IDENTIFICATION.— 
‘‘(i) IN
GENERAL.—The Secretary 
shall develop standards for the termination 
of identification of an individual as an at- 
risk beneficiary for prescription drug abuse 
under this paragraph. Under such stand-
ards such identification shall terminate as 
of the earlier of— 
‘‘(I) the date the individual dem-
onstrates that the individual is no 
longer likely, in the absence of the re-
strictions under this paragraph, to be 
an at-risk beneficiary for prescription 
drug abuse described in subparagraph 
(C)(i); and 
‘‘(II) the end of such maximum 
period of identification as the Sec-
retary may specify. 
‘‘(ii) 
RULE
OF
CONSTRUCTION.— 
Nothing in clause (i) shall be construed as 
preventing a plan from identifying an indi-
vidual as an at-risk beneficiary for pre-
scription drug abuse under subparagraph 
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(C)(i) after such termination on the basis 
of additional information on drug use oc-
curring after the date of notice of such ter-
mination. 
‘‘(G) FREQUENTLY
ABUSED
DRUG.—For 
purposes of this subsection, the term ‘frequently 
abused drug’ means a drug that is a controlled 
substance that the Secretary determines to be 
frequently abused or diverted. 
‘‘(H) DATA DISCLOSURE.—In the case of 
an at-risk beneficiary for prescription drug 
abuse whose access to coverage for frequently 
abused drugs under a prescription drug plan 
has been limited by a PDP sponsor under this 
paragraph, such PDP sponsor shall disclose 
data, including any necessary individually iden-
tifiable health information, in a form and man-
ner specified by the Secretary, about the deci-
sion to impose such limitations and the limita-
tions imposed by the sponsor under this part to 
other PDP sponsors that request such data. 
‘‘(I) EDUCATION.—The Secretary shall 
provide education to enrollees in prescription 
drug plans of PDP sponsors and providers re-
garding the drug management program for at- 
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risk beneficiaries described in this paragraph, 
including education— 
‘‘(i) provided by Medicare administra-
tive contractors through the improper pay-
ment outreach and education program de-
scribed in section 1874A(h); and 
‘‘(ii) through current education efforts 
(such as State health insurance assistance 
programs described in subsection (a)(1)(A) 
of section 119 of the Medicare Improve-
ments for Patients and Providers Act of 
2008 (42 U.S.C. 1395b–3 note)) and ma-
terials directed toward such enrollees. 
‘‘(J) 
APPLICATION
UNDER
MA–PD 
PLANS.—Pursuant to section 1860D–21(c)(1), 
the provisions of this paragraph apply under 
part D to MA organizations offering MA–PD 
plans to MA eligible individuals in the same 
manner as such provisions apply under this 
part to a PDP sponsor offering a prescription 
drug plan to a part D eligible individual.’’. 
(2) INFORMATION
FOR
CONSUMERS.—Section 
1860D–4(a)(1)(B) of the Social Security Act (42 
U.S.C. 1395w–104(a)(1)(B)) is amended by adding 
at the end the following: 
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‘‘(v) The drug management program 
for at-risk beneficiaries under subsection 
(c)(5).’’. 
(b) UTILIZATION MANAGEMENT PROGRAMS.—Sec-
tion 1860D–4(c) of the Social Security Act (42 U.S.C. 
1395w–104(c)), as amended by subsection (a)(1), is fur-
ther amended— 
(1) in paragraph (1), by inserting after sub-
paragraph (D) the following new subparagraph: 
‘‘(E) A utilization management tool to pre-
vent drug abuse (as described in paragraph 
(6)(A)).’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(6) UTILIZATION MANAGEMENT TOOL TO PRE-
VENT DRUG ABUSE.— 
‘‘(A) IN
GENERAL.—A tool described in 
this paragraph is any of the following: 
‘‘(i) A utilization tool designed to pre-
vent the abuse of frequently abused drugs 
by individuals and to prevent the diversion 
of such drugs at pharmacies. 
‘‘(ii) Retrospective utilization review 
to identify— 
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‘‘(I) individuals that receive fre-
quently abused drugs at a frequency 
or in amounts that are not clinically 
appropriate; and 
‘‘(II) providers of services or sup-
pliers that may facilitate the abuse or 
diversion of frequently abused drugs 
by beneficiaries. 
‘‘(iii) Consultation with the contractor 
described in subparagraph (B) to verify if 
an individual enrolling in a prescription 
drug plan offered by a PDP sponsor has 
been previously identified by another PDP 
sponsor as an individual described in 
clause (ii)(I). 
‘‘(B) REPORTING.—A PDP sponsor offer-
ing a prescription drug plan (and an MA orga-
nization offering an MA–PD plan) in a State 
shall submit to the Secretary and the Medicare 
drug integrity contractor with which the Sec-
retary has entered into a contract under section 
1893 with respect to such State a report, on a 
monthly basis, containing information on— 
‘‘(i) any provider of services or sup-
plier described in subparagraph (A)(ii)(II) 
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that is identified by such plan sponsor (or 
organization) during the 30-day period be-
fore such report is submitted; and 
‘‘(ii) 
the 
name 
and 
prescription 
records of individuals described in para-
graph (5)(C).’’. 
(c) EXPANDING ACTIVITIES OF MEDICARE DRUG IN-
TEGRITY CONTRACTORS (MEDICS).— 
(1) IN GENERAL.—Section 1893 of the Social 
Security Act (42 U.S.C. 1395ddd) is amended by 
adding at the end the following new subsection: 
‘‘(j) EXPANDING ACTIVITIES OF MEDICARE DRUG 
INTEGRITY CONTRACTORS (MEDICS).— 
‘‘(1) ACCESS
TO
INFORMATION.—Under con-
tracts entered into under this section with Medicare 
drug integrity contractors (including any successor 
entity to a Medicare drug integrity contractor), the 
Secretary shall authorize such contractors to directly 
accept prescription and necessary medical records 
from entities such as pharmacies, prescription drug 
plans, MA–PD plans, and physicians with respect to 
an individual in order for such contractors to pro-
vide information relevant to the determination of 
whether such individual is an at-risk beneficiary for 
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prescription drug abuse, as defined in section 
1860D–4(c)(5)(C). 
‘‘(2) REQUIREMENT
FOR
ACKNOWLEDGMENT 
OF REFERRALS.—If a PDP sponsor or MA organiza-
tion refers information to a contractor described in 
paragraph (1) in order for such contractor to assist 
in the determination described in such paragraph, 
the contractor shall— 
‘‘(A) acknowledge to the sponsor or organi-
zation receipt of the referral; and 
‘‘(B) in the case that any PDP sponsor or 
MA organization contacts the contractor re-
questing to know the determination by the con-
tractor of whether or not an individual has been 
determined to be an individual described such 
paragraph, shall inform such sponsor or organi-
zation of such determination on a date that is 
not later than 15 days after the date on which 
the sponsor or organization contacts the con-
tractor. 
‘‘(3) MAKING DATA AVAILABLE TO OTHER EN-
TITIES.— 
‘‘(A) IN GENERAL.—For purposes of car-
rying out this subsection, subject to subpara-
graph (B), the Secretary shall authorize MED-
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ICs to respond to requests for information from 
PDP sponsors and MA organizations, State 
prescription drug monitoring programs, and 
other entities delegated by such sponsors or or-
ganizations using available programs and sys-
tems in the effort to prevent fraud, waste, and 
abuse. 
‘‘(B) HIPAA COMPLIANT
INFORMATION 
ONLY.—Information may only be disclosed by a 
MEDIC under subparagraph (A) if the disclo-
sure of such information is permitted under the 
Federal regulations (concerning the privacy of 
individually identifiable health information) pro-
mulgated under section 264(c) of the Health 
Insurance Portability and Accountability Act of 
1996 (42 U.S.C. 1320d–2 note).’’. 
(2) OIG STUDY AND REPORT ON EFFECTIVE-
NESS OF MEDICS.— 
(A) STUDY.—The Inspector General of the 
Department of Health and Human Services 
shall conduct a study on the effectiveness of 
Medicare drug integrity contractors with which 
the Secretary of Health and Human Services 
has entered into a contract under section 1893 
of the Social Security Act (42 U.S.C. 1395ddd) 
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in identifying, combating, and preventing fraud 
under the Medicare Program, including under 
the authority provided under section 1893(j) of 
the Social Security Act, added by paragraph 
(1). 
(B) REPORT.—Not later than 1 year after 
the date of the enactment of this Act, the In-
spector General shall submit to Congress a re-
port on the study conducted under subpara-
graph (A). Such report shall include such rec-
ommendations for improvements in the effec-
tiveness of such contractors as the Inspector 
General determines appropriate. 
(d) TREATMENT OF CERTAIN COMPLAINTS FOR PUR-
POSES OF QUALITY OR PERFORMANCE ASSESSMENT.— 
Section 1860D–42 of the Social Security Act (42 U.S.C. 
1395w–152) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(d) TREATMENT
OF CERTAIN COMPLAINTS
FOR 
PURPOSES
OF
QUALITY
OR
PERFORMANCE
ASSESS-
MENT.—In conducting a quality or performance assess-
ment of a PDP sponsor, the Secretary shall develop or 
utilize existing screening methods for reviewing and con-
sidering complaints that are received from enrollees in a 
prescription drug plan offered by such PDP sponsor and 
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contract, or other agreement for which the Secretary of 
Health and Human Services provides funding— 
‘‘(1) knowingly presents or causes to be pre-
sented a specified claim (as defined in subsection 
(r)(6)) under such grant, contract, or other agree-
ment that the person knows or should know is false 
or fraudulent; 
‘‘(2) knowingly makes, uses, or causes to be 
made or used any false statement, omission, or mis-
representation of a material fact in any application, 
proposal, bid, progress report, or other document 
that is required to be submitted in order to directly 
or indirectly receive or retain funds provided in 
whole or in part by such Secretary pursuant to such 
grant, contract, or other agreement; 
‘‘(3) knowingly makes, uses, or causes to be 
made or used, a false record or statement material 
to a false or fraudulent specified claim under such 
grant, contract, or other agreement; 
‘‘(4) knowingly makes, uses, or causes to be 
made or used, a false record or statement material 
to an obligation to pay or transmit funds or property 
to such Secretary with respect to such grant, con-
tract, or other agreement, or knowingly conceals or 
knowingly and improperly avoids or decreases an ob-
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