H.R. 4876

Medicare Prescription Drug Abuse Prevention Act of 2016

This bill amends title XVIII (Medicare) of the Social Security Act to: (1) authorize a Medicare prescription drug plan (PDP) sponsor to establish a drug management program under which the PDP sponsor may limit an at-risk beneficiary's access to coverage for frequently abused drugs to include only those drugs that are prescribed by selected prescribers and dispensed by selected pharmacies; and (2) require a PDP sponsor to have in place a utilization management tool to prevent drug abuse.

With respect to a drug management program, a PDP sponsor must: (1) provide specified notice to a beneficiary who has been identified by the Centers for Medicare & Medicaid (CMS) as "at-risk" and consequently enrolled in the program; and (2) in selecting prescribers and dispensers, ensure that the beneficiary continues to have reasonable access to drugs. These determinations shall be subject to expedited reconsideration and appeal. A PDP sponsor must review and consider an at-risk beneficiary's preferences regarding prescriber and pharmacy selection.

Certain individuals, including those receiving hospice care or residing in a long-term care facility, are exempted from enrollment in a drug management program.

CMS must, for purposes of quality or performance assessments, review and consider complaints received from at-risk beneficiaries regarding lack of access due to their enrollment in a drug management program. In addition, CMS must establish rules and procedures requiring a PDP sponsor to provide specified program data.