; (2) in each of subparagraphs (C)(i) and (D)(i), by striking paragraph (4) and inserting paragraph (4), and subject to subparagraph (E) ; and (3) by adding at the end the following new subparagraph: (E) Monthly out-of-pocket cost sharing maximum (i) In general For plan years beginning on or after January 1, 2022, the Secretary shall through regulation establish a process to allow an enrollee in a prescription drug plan who incurs costs (as described in paragraph (4)(C)) equal to or greater than a significant percentage of the annual out-of-pocket threshold specified in paragraph (4)(B) within a one month time period to choose to pay the total amount of such costs owed, in equal installments in the remaining months of the plan year up to the total amount of such annual out-of-pocket threshold. (ii) Definition of significant percent For purposes of the process described in clause (i), the Secretary shall through regulation provide for a definition of the term significant percentage with respect to a percentage of the annual out-of-pocket threshold specified in paragraph (4)(B) but in no case shall the significant percentage be less than 50 percent or more than 100 percent of the annual out-of-pocket threshold. . (b) Alternative prescription drug coverage Section 1860D–2(c) of the Social Security Act ( 42 U.S.C. 1395w–102(c) ) is amended by adding at the end the following new paragraph: (4) Same monthly out-of-pocket cost sharing maximum For plan years beginning on or after January 1, 2022, the coverage provides the monthly out-of-pocket cost sharing maximum required under subsection (b)(2)(E). .