At-risk determination

At-risk determination means a decision made under a plan sponsor's drug management program in accordance with 423.153 that involves the identification of an individual as an at-risk beneficiary for prescription drug abuse; a limitation, or the continuation of a limitation, on an at-risk beneficiary's access to coverage for frequently abused drugs (that is, a beneficiary specific point-of-sale edit or the selection of a prescriber and/or pharmacy and implementation of lock-in, or); and information sharing for subsequent plan enrollments.


42 CFR § 423.560

Scoping language

As used in this subpart, unless the context indicates otherwise -

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