Generic Drug Pricing Fairness Act - Amends part D (Voluntary Prescription Drug Benefit Program) of title XVIII (Medicare) of the Social Security Act to require each contract entered into with a prescription drug plan (PDP) sponsor with respect to a PDP the sponsor offers to prohibit the PDP from entering into a contract with any pharmacy benefits manager (PBM) to manage the prescription drug coverage provided under such plan, or to control the costs of the prescription drug coverage under it, unless the PBM adheres to specified criteria when handling personally identifiable utilization and claims data or other sensitive patient data.
Revises requirements for contracts with PDP sponsors to require that the PDP sponsor disclose to applicable pharmacies the sources used for making any update of the prescription drug pricing standard, and if the source for such a standard is not publicly available, disclose to such pharmacies all individual drug prices to be so updated in advance of their use for the reimbursement of claims.
Requires the PDP sponsor, as well, to establish a process to appeal, investigate, and resolve disputes regarding individual drug prices that are less than the pharmacy acquisition price for a drug.
Directs the Secretary of Defense (DOD), with respect to the TRICARE retail pharmacy program, to ensure that a contract entered into with a TRICARE managed care support contractor includes requirements to ensure the provision of information regarding the pricing standard for prescription drugs.
Establishes criteria to which a carrier and a PBM must adhere under a contract or an approved plan under which the carrier has an agreement with the PBM to manage prescription drug coverage or to control the costs of such coverage.
Prohibits a PBM under such criteria from: (1) transmitting to a pharmacy owned by the PBM any personally identifiable utilization or claims data relating to an enrolled individual who has not voluntarily elected in writing or via secure electronic means to fill that particular prescription at such a pharmacy; or (2) requiring any enrolled individual to use a retail pharmacy, mail order pharmacy, specialty pharmacy, or other pharmacy entity in which the PBM has an ownership interest, or that has an ownership interest in the PBM, or give an incentive to encourage an enrollee to use the pharmacy if the incentive applies only to those pharmacies.
Requires any contract or approved plan providing for a reimbursement standard with respect to a PDP to require the carrier to: (1) update the standard at least once every seven days to reflect the market price of a drug accurately; (2) disclose to pharmacies the sources used for making any such update; (3) make advance disclosure to those pharmacies of all individual drug prices to be updated if the source for a standard is not publicly available; and (4) establish a process to appeal, investigate, and resolve disputes regarding individual drug prices less than the pharmacy acquisition price.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5815 Introduced in House (IH)]
113th CONGRESS
2d Session
H. R. 5815
To amend title XVIII of the Social Security Act to provide for pharmacy
benefits manager standards under the Medicare prescription drug program
to further transparency of payment methodologies to pharmacies, and for
other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 9, 2014
Mr. Collins of Georgia (for himself and Mr. Loebsack) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Ways and Means, Armed
Services, and Oversight and Government Reform, 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 amend title XVIII of the Social Security Act to provide for pharmacy
benefits manager standards under the Medicare prescription drug program
to further transparency of payment methodologies to pharmacies, and for
other purposes.
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 ``Generic Drug Pricing Fairness Act''.
SEC. 2. PHARMACY BENEFITS MANAGER STANDARDS UNDER THE MEDICARE PROGRAM.
(a) In General.--Section 1860D-12(b) of the Social Security Act (42
U.S.C. 1395w-112(b)) is amended by adding at the end the following new
paragraph:
``(7) Pharmacy benefits manager transparency
requirements.--Each contract entered into with a PDP sponsor
under this part with respect to a prescription drug plan
offered by such sponsor shall provide that the PDP may not
enter into a contract with any pharmacy benefits manager
(referred to in this paragraph as a `PBM') to manage the
prescription drug coverage provided under such plan, or to
control the costs of the prescription drug coverage under such
plan, unless the PBM adheres to the following criteria when
handling personally identifiable utilization and claims data or
other sensitive patient data:
``(A) The PBM may not transmit any personally
identifiable utilization or claims data, with respect
to a plan enrollee, to a pharmacy owned by a PBM if the
plan enrollee has not voluntarily elected in writing or
via secure electronic means to fill that particular
prescription at the PBM-owned pharmacy.
``(B) The PBM may not require that a plan enrollee
use a retail pharmacy, mail order pharmacy, specialty
pharmacy, or other pharmacy entity providing pharmacy
services in which the PBM has an ownership interest or
that has an ownership interest in the PBM or provide an
incentive to a plan enrollee to encourage the enrollee
to use a retail pharmacy, mail order pharmacy,
specialty pharmacy, or other pharmacy entity providing
pharmacy services in which the PBM has an ownership
interest or that has an ownership interest in the PBM,
if the incentive is applicable only to such
pharmacies.''.
(b) Regular Update of Prescription Drug Pricing Standard.--
Paragraph (6) of section 1860D-12(b) of the Social Security Act (42
U.S.C. 1395w-112(b)) is amended to read as follows:
``(6) Regular update of prescription drug pricing
standard.--
``(A) In general.--If the PDP sponsor of a
prescription drug plan uses a standard for
reimbursement (as described in subparagraph (B)) of
pharmacies based on the cost of a drug, each contract
entered into with such sponsor under this part with
respect to the plan shall provide that the sponsor
shall--
``(i) update such standard not less
frequently than once every 7 days, beginning
with an initial update on January 1 of each
year, to accurately reflect the market price of
acquiring the drug;
``(ii) disclose to applicable pharmacies
the sources used for making any such update;
``(iii) if the source for such a standard
for reimbursement is not publicly available,
disclose to the applicable pharmacies all
individual drug prices to be so updated in
advance of the use of such prices for the
reimbursement of claims; and
``(iv) establish a process to appeal,
investigate, and resolve disputes regarding
individual drug prices that are less than the
pharmacy acquisition price for such drug.
``(B) Prescription drug pricing standard defined.--
For purposes of subparagraph (A), a standard for
reimbursement of a pharmacy is any methodology or
formula for varying the pricing of a drug or drugs
during the term of the pharmacy reimbursement contract
that is based on the cost of the drug involved,
including drug pricing references and amounts that are
based upon average wholesale price, wholesale average
cost, average manufacturer price, average sales price,
maximum allowable cost (MAC), or other costs, whether
publicly available or not.''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2015.
SEC. 3. REGULAR UPDATE OF PRESCRIPTION DRUG PRICING STANDARD UNDER
TRICARE RETAIL PHARMACY PROGRAM.
Section 1074g(d) of title 10, United States Code, is amended by
adding at the end the following new paragraph:
``(3) To the extent practicable, with respect to the TRICARE retail
pharmacy program described in subsection (a)(2)(E)(ii), the Secretary
shall ensure that a contract entered into with a TRICARE managed care
support contractor includes requirements described in section 1860D-
12(b)(6) of the Social Security Act (42 U.S.C. 1395w-112(b)(6)) to
ensure the provision of information regarding the pricing standard for
prescription drugs.''.
SEC. 4. PRESCRIPTION DRUG TRANSPARENCY IN THE FEDERAL EMPLOYEE HEALTH
BENEFITS PROGRAM.
(a) In General.--Section 8902 of title 5, United States Code, is
amended by adding at the end the following new subsections:
``(p) A contract may not be made or a plan approved under this
chapter under which a carrier has an agreement with a pharmacy benefits
manager (in this subsection referred to as a `PBM') to manage
prescription drug coverage or to control the costs of the prescription
drug coverage unless the carrier and PBM adhere to the following
criteria:
``(1) The PBM may not transmit any personally identifiable
utilization or claims data with respect to an individual
enrolled under such contract or plan to a pharmacy owned by the
PBM if the individual has not voluntarily elected in writing or
via secure electronic means to fill that particular
prescription at such a pharmacy.
``(2) The PBM may not require that an individual enrolled
under such contract or plan use a retail pharmacy, mail order
pharmacy, specialty pharmacy, or other pharmacy entity
providing pharmacy services in which the PBM has an ownership
interest or that has an ownership interest in the PBM or
provide an incentive to a plan enrollee to encourage the
enrollee to use a retail pharmacy, mail order pharmacy,
specialty pharmacy, or other pharmacy entity providing pharmacy
services in which the PBM has an ownership interest or that has
an ownership interest in the PBM, if the incentive is
applicable only to such pharmacies.
``(q)(1) If a contract made or plan approved under this chapter
provides for a standard for reimbursement (as described in paragraph
(2)) with respect to a prescription drug plan, such contract or plan
shall provide that the applicable carrier--
``(A) update such standard not less frequently than once
every 7 days, beginning with an initial update on January 1 of
each year, to accurately reflect the market price of acquiring
the drug;
``(B) disclose to applicable pharmacies the sources used
for making any such update;
``(C) if the source for such a standard for reimbursement
is not publicly available, disclose to the applicable
pharmacies all individual drug prices to be so updated in
advance of the use of such prices for the reimbursement of
claims; and
``(D) establish a process to appeal, investigate, and
resolve disputes regarding individual drug prices that are less
than the pharmacy acquisition price for such drug.
``(2) For purposes of paragraph (1), a standard for reimbursement
of a pharmacy is any methodology or formula for varying the pricing of
a drug or drugs during the term of the pharmacy reimbursement contract
that is based on the cost of the drug involved, including drug pricing
references and amounts that are based upon average wholesale price,
wholesale average cost, average manufacturer price, average sales
price, maximum allowable cost, or other costs, whether publicly
available or not.''.
(b) Application.--The amendment made by subsection (a) shall apply
to any contract entered into under section 8902 of title 5, United
States Code, on or after the date of enactment of this section.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Armed Services, and Oversight and Government Reform, 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 the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Armed Services, and Oversight and Government Reform, 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 the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Armed Services, and Oversight and Government Reform, 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 the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Armed Services, and Oversight and Government Reform, 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 the Subcommittee on Energy and Power.
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