§ 1395w–153 — Condition For Coverage Of Drugs Under This Part

(a) In order for coverage to be available under this part for covered part D drugs (as defined in section 1395w–102(e) of this title) of a manufacturer, the manufacturer must— (1) participate in— (A) for 2011 through 2024, the Medicare coverage gap discount program under section 1395w–114a of this title; and (B) for 2025 and each subsequent year, the manufacturer discount program under section 1395w–114c of this title; (2) have entered into and have in effect— (A) for 2011 through 2024, an agreement described in subsection (b) of section 1395w–114a of this title with the Secretary; and (B) for 2025 and each subsequent year, an agreement described in subsection (b) of section 1395w–114c of this title with the Secretary; and (3) have entered into and have in effect, under terms and conditions specified by the Secretary, a contract with a third party that the Secretary has entered into a contract with under subsection (d)(3) of section 1395w–114a of this title. (b) Paragraphs (1)(A), (2)(A), and (3) of subsection (a) shall apply to covered part D drugs dispensed under this part on or after January 1, 2011, and before January 1, 2025, and paragraphs (1)(B) and (2)(B) of such subsection shall apply to covered part D drugs dispensed under this part on or after January 1, 2025. (1) Subject to paragraph (2), subsection (a) shall not apply to the dispensing of a covered part D drug if— (A) the Secretary has made a determination that the availability of the drug is essential to the health of beneficiaries under this part; or (B) December 31, 2011, there were extenuating circumstances. (2) Paragraph (1)(A) shall not apply to a covered part D drug of a manufacturer for any period described in section 5000D(c)(1) of the Internal Revenue Code of 1986 with respect to the manufacturer. (d) In this section, the term “manufacturer” has the meaning given such term in section 1395w–114a(g)(5) of this title.