Protect Beneficiaries from Middlemen Act

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5197 Introduced in House (IH)]

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119th CONGRESS
  1st Session
                                H. R. 5197

 To amend title XVIII of the Social Security Act to limit cost sharing 
                 for drugs under the Medicare program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 8, 2025

 Ms. Malliotakis 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 amend title XVIII of the Social Security Act to limit cost sharing 
                 for drugs under the Medicare program.

    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 ``Protect Beneficiaries from Middlemen 
Act''.

SEC. 2. LIMITATION ON COST SHARING TO NET PRICE AMOUNT UNDER MEDICARE 
              PART D.

    (a) In General.--Section 1860D-2 of the Social Security Act (42 
U.S.C. 1395w-102) is amended--
            (1) in subsection (b)--
                    (A) in paragraph (2)(A), by striking ``(8) and 
                (9)'' and inserting ``(8), (9), and (10)'';
                    (B) in paragraph (9)(B)(ii), by striking ``For a 
                plan year'' and inserting ``Subject to paragraph (10), 
                for a plan year''; and
                    (C) by adding at the end the following new 
                paragraph:
            ``(10) Limitation on cost sharing to net price amount.--
                    ``(A) In general.--For a plan year beginning on or 
                after January 1, 2027, the coverage provides benefits 
                for a supply of a covered part D drug dispensed by a 
                pharmacy, for costs in excess of the deductible 
                specified in paragraph (1) and prior to an individual 
                reaching the out-of-pocket threshold under paragraph 
                (4), with cost-sharing for a month's supply that does 
                not exceed the average net price for such a supply of 
                such drug during such plan year (or, if lower, the 
                applicable cash price for such a supply of such drug so 
                dispensed by such pharmacy).
                    ``(B) Definitions.--In this paragraph:
                            ``(i) Applicable cash price.--The term 
                        `applicable cash price' means, with respect to 
                        a supply of a covered part D drug dispensed by 
                        a pharmacy, the price that such pharmacy would 
                        charge for such supply of such drug dispensed 
                        to an individual without benefits for such drug 
                        under any Federal health care program (as 
                        defined in section 1128B), a group health plan 
                        or group or individual health insurance 
                        coverage (as such terms are defined in section 
                        2791 of the Public Health Service Act), or the 
                        program established under chapter 89 of title 
                        5, United States Code.
                            ``(ii) Average net price.--The term 
                        `average net price' means, with respect to a 
                        supply of a covered part D drug, a prescription 
                        drug plan, and a plan year, the average amount 
                        paid under such plan (including any amounts 
                        paid by an individual enrolled under such plan 
                        as cost sharing for such drug) as payment for 
                        such a supply of such drug dispensed during 
                        such year, less any rebates or other forms of 
                        remuneration received under such plan with 
                        respect to such drug.''; and
            (2) in subsection (c), by adding at the end the following 
        new paragraph:
            ``(7) Cost sharing limited to net price.--The coverage is 
        provided in accordance with subsection (b)(10).''.
    (b) Conforming Amendment to Cost-Sharing for Low-Income 
Individuals.--Section 1860D-14(a)(1)(D)(iii) of the Social Security Act 
(42 U.S.C. 1395w-114(a)(1)(D)(iii)) is amended by adding at the end the 
following new sentence: ``For plan year 2027 and subsequent plan years, 
the copayment amount applicable under this clause to a supply of a 
covered part D drug dispensed to the individual may not exceed the 
amount provided under section 1860D-2(b)(10).''.
    (c) GAO Report.--Not later than January 1, 2029, the Comptroller 
General of the United States shall submit to Congress a report 
containing--
            (1) an analysis of compliance with the amendments made by 
        this section;
            (2) an analysis of enforcement of such amendments;
            (3) recommendations with respect to improving such 
        enforcement; and
            (4) recommendations relating to improving public 
        disclosure, and public awareness of, the requirements of such 
        amendments.
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