Federal regulations · Through 2026-08-25 · Newer source version available

42 CFR 423.2736: Requirement for point-of-sale discounts.

(a) Point-of-sale discounts. Part D sponsors must provide applicable discounts on applicable drugs at the point of sale on behalf of the manufacturer. As part of this process, plan sponsors must determine—
(1) Whether an enrollee is an applicable beneficiary as described in § 423.100;
(2) Whether a drug is an applicable drug as described in § 423.100; and
(3) The amount of the discount, in accordance with § 423.2712.
(b) Direct member reimbursement (DMR). Part D sponsors must provide applicable discounts on claims for applicable drugs submitted by applicable beneficiaries as DMRs, including out-of-network and in-network paper claims, if such claims are payable under the Part D plan. While the sponsor must account for the discount in adjudicating the DMR request and the associated PDE submitted to CMS, the point-of-sale requirement does not apply.
(c) Pharmacy prompt payment. Part D sponsors must reimburse a network pharmacy (as defined in § 423.100) the amount of the applicable discount within the applicable number of calendar days (as defined in § 423.100) of the date of dispensing (as defined in § 423.100) of an applicable drug, consistent with § 423.520.
(d) Prescription drug event (PDE) requirements. Part D sponsors must report the applicable discounts made available to their enrollees under the Manufacturer Discount Program on the PDE records associated with such discounts.
(e) Retroactive adjustments. Part D sponsors must make retroactive adjustments to applicable discounts as necessary to reflect applicable changes, including changes to the claim, beneficiary eligibility, or benefit phase determined after the date of dispensing.

Where this section sits in the code

Title 42—Public Health
CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B—MEDICARE PROGRAM
PART 423—VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
Subpart AA—Medicare Part D Manufacturer Discount Program

(1) Whether an enrollee is an applicable beneficiary as described in § 423.100;

(2) Whether a drug is an applicable drug as described in § 423.100; and

(3) The amount of the discount, in accordance with § 423.2712.

(b) Direct member reimbursement (DMR). Part D sponsors must provide applicable discounts on claims for applicable drugs submitted by applicable beneficiaries as DMRs, including out-of-network and in-network paper claims, if such claims are payable under the Part D plan. While the sponsor must account for the discount in adjudicating the DMR request and the associated PDE submitted to CMS, the point-of-sale requirement does not apply.

(c) Pharmacy prompt payment. Part D sponsors must reimburse a network pharmacy (as defined in § 423.100) the amount of the applicable discount within the applicable number of calendar days (as defined in § 423.100) of the date of dispensing (as defined in § 423.100) of an applicable drug, consistent with § 423.520.

(d) Prescription drug event (PDE) requirements. Part D sponsors must report the applicable discounts made available to their enrollees under the Manufacturer Discount Program on the PDE records associated with such discounts.

(e) Retroactive adjustments. Part D sponsors must make retroactive adjustments to applicable discounts as necessary to reflect applicable changes, including changes to the claim, beneficiary eligibility, or benefit phase determined after the date of dispensing.

Collected 2026-08-27T02:26:11Z. Source file · JSON

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