Patient Health and Real Medication Access Cost Savings Act of 2009 or the PHARMACY Bill - Declares that a consumer shall have the right to choose to purchase prescription drugs from any domestic pharmacy that meets all applicable federal and state license and permit requirements.
Directs the Secretary of Health and Human Services (HHS) to issue regulations that: (1) prohibit a pharmacy benefit manager (PBM) from providing incentives to, encouraging, or requiring pharmacy benefit plan enrollees to use certain pharmacies or from excluding an eligible pharmacy from a plan's pharmacy network; (2) require a PBM to ensure that pharmacy benefit plan enrollees pay a specified copayment for brand name drugs; (3) require a PBM to reimburse a pharmacy in the network of a pharmacy benefit plan that is federally funded, at specified rates, for brand-name drugs, generic drugs, and additional professional services; (4) require a PBM to be reimbursed by a pharmacy benefit plan sponsor for adjudicating and processing claims; (5) limit the amount that a PBM charges a pharmacy benefit plan sponsor for a drug that is dispensed to enrollees to the amount the PBM paid the pharmacy for such drug; (6) require a manufacturer of prescription drugs to pay all rebates directly to the pharmacy benefit plan sponsor and not to a PBM; and (7) require a pharmacy benefit plan sponsor to provide a list of the wholesale acquisition costs of the top 500 most frequently prescribed drugs to physicians in a plan any insurance-related charge of which is underwritten by a federal, state, or local government.
Amends title XVIII (Medicare) of the Social Security Act to include pharmacist services as "medical and other health services" under Medicare.
Directs the Secretary, by January 1, 2011, to establish a pharmaceutical access program to provide affordable prescription drugs to individuals who receive drug benefits under federal programs (except Medicaid). Requires: (1) a pharmacy that dispenses prescription drugs in the United States to remit to the Secretary 50 cents for each brand name prescription and $1.00 for generic drug prescription dispensed; and (2) the sponsor of a pharmacy benefit plan that is not federally funded to increase the professional dispensing fee paid to pharmacies by the same amounts. Requires the use of funds generated from such fees to provide affordable access to prescription drugs to low-income individuals who have enrolled in the program.
[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4199 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 4199
To ensure patient choice in pharmacies by regulating pharmacy benefit
managers and to establish a program to improve access to prescription
drugs for certain individuals.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 3, 2009
Mr. Butterfield (for himself, Mr. Jones, Mr. Kissell, Mr. McIntyre, Mr.
Coble, Mr. Miller of North Carolina, Mr. Alexander, and Mrs. McMorris
Rodgers) introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on
Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To ensure patient choice in pharmacies by regulating pharmacy benefit
managers and to establish a program to improve access to prescription
drugs for certain individuals.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Patient Health and Real Medication
Access Cost Savings Act of 2009'' or the ``PHARMACY Bill''.
SEC. 2. PATIENT CHOICE.
A consumer shall have the right to choose to purchase prescription
drugs from any domestic pharmacy that meets all applicable Federal and
State licence and permit requirements.
SEC. 3. REGULATION OF PHARMACY BENEFIT MANAGERS.
Not later than January 1, 2011, the Secretary of Health and Human
Services shall issue regulations to ensure the following:
(1) Access to and choice of pharmacy.--
(A) Incentives.--A pharmacy benefit manager
(referred to in this section as a ``PBM'') may not
provide incentives (including variations in premiums,
deductibles, co-payments, or co-insurance rates) to
enrollees of pharmacy benefit plans administered by
such PBM for the purpose of encouraging such enrollees
to use certain pharmacies (including mail order
pharmacies, speciality drug pharmacies, or other
entities) unless the PBM offers the same incentives for
all pharmacies in the network for such plan.
(B) Mandates.--A PBM may not refer, coerce, or
mandate that an enrollee of a pharmacy benefit plan
administered by such PBM use a specific mail order
pharmacy, specialty drug pharmacy, or other entity--
(i) if the PBM has an ownership interest in
a such pharmacy or entity; or
(ii) if the pharmacy or entity has an
ownership interest in such PBM.
(C) Pharmacy networks.--A PBM or pharmacy benefit
plan sponsor may not exclude a pharmacy from a pharmacy
network if--
(i) the pharmacy agrees to the terms of the
network contract;
(ii) the pharmacy meets all applicable
Federal and State licence and permit
requirements; and
(iii) the owners of the pharmacy have not
been convicted of a Federal crime related to
owning or managing a pharmacy.
(2) Encourage generic drugs.--
(A) Cost to consumers.--
(i) In general.--Subject to clause (iii), a
PBM shall ensure that enrollees of pharmacy
benefit plans administered by such a PBM pay a
copayment of 20 percent for brand name drugs,
not to exceed a maximum amount of $150 per
prescription.
(ii) Annual updates to amount.--The maximum
amount under clause (i) shall be updated
annually for inflation based on the consumer
price index.
(iii) Exception for state medicaid
programs.--Clause (i) shall not apply to a PBM
with respect to enrollees of a State Medicaid
program that limits or prohibits copayments for
prescription drugs.
(B) Payments to pharmacies.--
(i) In general.--With respect to a pharmacy
benefit plan that is at least partially funded
with Federal funds, the PBM administering such
plan shall reimburse a pharmacy that is in the
network for such a plan at least--
(I) 107 percent of the Wholesale
Acquisition Cost plus a minimum
professional dispensing fee of $4.25
for a prescription for a brand-name
drug;
(II) 190 percent of the Federal
Upper Limit plus a minimum professional
dispensing fee of $8.50 for a
prescription for a generic drug; and
(III) a professional service fee
for any additional pharmacy services
provided by the pharmacy, in an amount
set by the Secretary of Health and
Human Services.
(ii) Adjustment for inflation.--The
professional dispensing fees under clause (i)
shall be adjusted annually for inflation, based
on the consumer price index.
(3) Payments and charges between pbms and pharmacy benefit
plan sponsors.--
(A) Payments.--A PBM shall be reimbursed by a
pharmacy benefit plan sponsor for adjudicating and
processing claims in behalf of such sponsor at a rate
that is determined by such sponsor.
(B) Charges to pharmacy benefit plan sponsors for
drugs dispensed to plan enrollees.--The amount that a
PBM charges a pharmacy benefit plan sponsor for a drug
that is dispensed to enrollee of a pharmacy benefit
plan administered by such PBM may not be greater than
the amount that the PBM paid the pharmacy for such drug
(including any associated professional dispensing fee).
(4) Treatment of drug manufacturer rebates.--
(A) No rebates to pbms.--A manufacturer of
prescription drugs--
(i) shall pay all rebates, as defined in
section 5(6), directly to the pharmacy benefit
plan sponsor; and
(ii) shall not pay such rebates to a PBM.
(B) Negotiation allowed.--A PBM may negotiate
rebate amounts with a manufacturer of prescription
drugs on behalf of a pharmacy benefit plan sponsor.
(5) Provision of cost information to physicians.--In the
case that the premium, deductible, co-payments, co-insurance,
or other insurance-related charge under a pharmacy benefit plan
is underwritten, in whole or in part, by a Federal, State, or
local government, the pharmacy benefit plan sponsor shall
provide a list of the wholesale acquisition costs of the top
500 most frequently prescribed drugs to physicians who are
licenced to prescribe drugs and who provide treatment to
enrollees in such a plan.
(6) Treatment of pharmacists as professional health care
providers.--Section 1861(s)(2) of the Social Security Act (42
U.S.C. 1395x(s)(2)) is amended--
(A) by striking ``and'' at the end of subparagraph
(DD);
(B) by adding ``and'' at the end of subparagraph
(EE); and
(C) by inserting after subparagraph (EE), the
following new subparagraph:
``(FF) pharmacist services;''.
SEC. 4. PHARMACEUTICAL ACCESS PROGRAM.
(a) Establishment.--Not later than January 1, 2011, the Secretary
of Health and Human Services shall establish a pharmaceutical access
program to provide affordable access to prescription drugs to
individuals who receive drug benefits under Federal programs (except
for the Medicaid program under title XIX of the Social Security Act).
(b) Eligibility.--Any individual in a State shall be eligible to
enroll in the program under subsection (a).
(c) Fees.--
(1) In general.--A pharmacy that dispenses prescription
drugs in the United States shall remit to the Secretary of
Health and Human Services--
(A) $0.50 for each prescription dispensed by such
pharmacy for a brand name drug; and
(B) $1.00 for each prescription dispensed by such
pharmacy for a generic drug.
(2) Treatment for inflation.--The fees under paragraph (1)
shall be adjusted annually for inflation, based on the consumer
price index.
(3) Treatment of medicaid programs.--The rule under
paragraph (1) shall not apply to drugs dispensed under a State
Medicaid program under title XIX of the Social Security Act.
(4) Increase in professional dispensing fee for private
plans.--The professional dispensing fee paid to pharmacies by a
pharmacy benefit plan that is not funded by any Federal funds
shall be increased by such plan sponsor--
(A) by $0.50 for each brand name prescription; and
(B) by $1.00 for each generic prescription.
(d) Use of Funds.--Funds generated under subsection (c) shall be
used solely to provide affordable access to prescription drugs to low-
income individuals who have enrolled in the program under subsection
(a).
SEC. 5. DEFINITIONS.
For purposes of this Act:
(1) Brand name drugs.--The term ``brand name drug'' means a
prescription drug that is under patent by the drug's original
manufacturer and is protected from competition by other
manufacturers of prescription drugs.
(2) Generic drug.--The term ``generic drug'' means a
prescription drug that has lost patient protection provided to
a single manufacturer or multiple manufacturers and is widely
available from multiple manufacturers.
(3) Pharmacy benefit plan.--The term ``pharmacy benefit
plan'' means an insurance plan or insurance coverage that
provides benefits for prescription drugs, including a group
health plan (as such term is defined in section 733(a) of the
Patient Health and Real Medication Access Cost Savings Act of
2009 (29 U.S.C. 1191b(a))) that provides prescription drug
benefits.
(4) Professional dispensing fee.--The term ``professional
dispensing fee'' means the fee paid for the dispensing of a
drug by the pharmacist and excludes any reimbursement for the
cost of the drug.
(5) Professional service fee.--The term ``professional
service fee'' means a fee paid to a pharmacy for professional
services preformed by a pharmacist, excluding dispensing drugs
and any reimbursement for the cost of the drug. Such term may
include medication reviews, injections, and cholesterol checks.
(6) Rebate.--The term ``rebate'' means any item of value,
including monetary value, that is distributed by the
manufacturer conditional upon the receipt of a payment for
drugs produced by such manufacturer.
<all>
Introduced in House
Introduced in House
Sponsor introductory remarks on measure. (CR E2890-2891)
Referred to House Energy and Commerce
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to House Ways and Means
Referred to the Subcommittee on Health.
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