No official summary available for this bill.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6609 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 6609
To amend titles XI, XVIII, and XIX of the Social Security Act to
establish certain requirements under Medicare and Medicaid with respect
to prescription drug benefits and pharmacy benefit managers.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 11, 2025
Mr. Auchincloss (for himself, Mrs. Harshbarger, Mr. Comer, Mr. Carter
of Georgia, Mr. Ciscomani, Mr. Moulton, Mr. Deluzio, Mr. Peters, Ms.
Tlaib, Ms. Budzinski, Mr. Krishnamoorthi, Mr. Khanna, Mr. Lynch, Mr.
Goldman of Texas, Mr. Cohen, Ms. Pressley, Mr. Vicente Gonzalez of
Texas, Mr. Moore of Alabama, Mr. Subramanyam, Mr. Pocan, Mr. Bishop,
and Ms. McCollum) 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 titles XI, XVIII, and XIX of the Social Security Act to
establish certain requirements under Medicare and Medicaid with respect
to prescription drug benefits and pharmacy benefit managers.
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 ``Pharmacists Fight Back in Medicare
and Medicaid Act''.
SEC. 2. ESTABLISHING CERTAIN REQUIREMENTS WITH RESPECT TO PBMS.
(a) Medicare.--
(1) Prescription drug plans.--Section 1860D-12 of the
Social Security Act (42 U.S.C. 1395w-112) is amended by adding
at the end the following new subsection:
``(h) Requirements Relating to Pharmacy Benefit Managers.--For plan
years beginning on or after January 1, 2027:
``(1) In general.--Each contract entered into with a PDP
sponsor under this part with respect to a prescription drug
plan offered by such sponsor shall provide--
``(A) that the sponsor (and any pharmacy benefit
manager acting on behalf of such sponsor, including any
affiliate of such PBM, as applicable)--
``(i) shall comply with the pharmacy
payment requirements described in paragraph
(2);
``(ii) shall comply with the rebate pass-
through requirements described in paragraph
(3);
``(iii) shall comply with the reporting
requirement described in paragraph (4); and
``(iv) may not engage in steering; and
``(B) that any pharmacy benefit manager acting on
behalf of such sponsor has a written agreement with the
PDP sponsor under which the PBM, and any affiliate of
such PBM, as applicable, agrees to meet the
requirements described in subparagraph (A).
``(2) Pharmacy payment requirements.--For purposes of
paragraph (1)(A)(i), the pharmacy payment requirements
described in this paragraph are, with respect to a PDP sponsor
(and a PBM acting on behalf of such sponsor, including any
affiliate of such PBM, as applicable) the following:
``(A) The sponsor, PBM, or affiliate reimburses an
in-network pharmacy for the ingredient cost of a
covered part D drug in an amount equal to the sum of--
``(i) the national average drug acquisition
cost for the drug as of the day that the
pharmacy submits a claim for payment for such
drug (as determined based upon the retail
survey prices obtained under section
1927(f)(1)), or, in the case of a drug for
which no such national average drug acquisition
cost is available, the wholesale acquisition
cost for such drug as of such day; and
``(ii) an amount equal to 4 percent of the
amount described in clause (i), or $50,
whichever is less.
``(B) With respect to each covered part D drug
obtained from an in-network pharmacy by an individual
enrolled in the prescription drug plan, the sponsor,
PBM, or affiliate--
``(i) pays such pharmacy a dispensing fee
that is equal to the dispensing fee paid for
such drug under the State plan under title XIX
in the State in which such pharmacy is located,
as reported by the State under section
1927(f)(2); and
``(ii) does not require such individual to
reimburse such dispensing fee or otherwise
increase the amount owed by such individual
with respect to such drug to account for such
dispensing fee.
``(C) The sponsor, PBM, or affiliate does not
impose any fee or other payment requirement upon an in-
network pharmacy that would have the effect of reducing
the amount received by the pharmacy under the other
provisions of this paragraph.
``(3) Rebate pass-through requirements.--For purposes of
paragraph (1)(A)(ii), the rebate pass-through requirements
described in this paragraph are, with respect to a PDP sponsor
(and a PBM acting on behalf of such sponsor, including any
affiliate of such PBM, as applicable), that, in the case that
such sponsor, PBM, or affiliate receives a manufacturer rebate
in connection with a covered part D drug--
``(A) in the case that such drug is obtained from
an in-network pharmacy by an individual enrolled in the
prescription drug plan, the PDP sponsor, PBM, or
affiliate applies, at the point of sale of such drug, a
reduction to the amount of any coinsurance or copayment
owed by such individual with respect to such drug, such
that the amount of coinsurance or copayment so owed is
calculated based on an amount equal to the
reimbursement amount for such drug determined under
paragraph (2)(A), less the amount of such rebate (or,
in the case of a rebate described in paragraph
(5)(B)(ii), the amount of such rebate that is
attributable to such drug and such individual); and
``(B) in the case that the entity receiving the
manufacturer rebate in connection with such drug is a
PBM (or any affiliate of such PBM), the PBM (or
affiliate) remits to the PDP sponsor an amount (in this
subparagraph referred to as the `rebate remittance
payment') equal to the amount of such rebate (or, in
the case of a rebate described in paragraph (5)(B)(ii),
the amount of such rebate that is attributable to such
drug and such individual), less the amount by which the
coinsurance or copayment owed by an individual enrolled
in the prescription drug plan with respect to such drug
was reduced pursuant to subparagraph (A); and
``(C) in the case that such drug is obtained from
an in-network pharmacy by an individual enrolled in the
prescription drug plan who is a subsidy eligible
individual (as defined in section 1860D-14(a)(3)), the
PDP sponsor remits to the Secretary, at such time and
in such manner as the Secretary may specify--
``(i) in the case that the entity receiving
the manufacturer rebate in connection with such
drug is a PBM (or any affiliate of such PBM),
the amount received by the sponsor under
subparagraph (B) with respect to such drug and
such individual; and
``(ii) in the case that the entity
receiving the manufacturer rebate in connection
with such drug is the PDP sponsor, an amount
equal to the amount of such rebate (or, in the
case of a rebate described in paragraph
(5)(B)(ii), the amount of such rebate that is
attributable to such drug and such individual),
less the amount by which the coinsurance or
copayment owed by such individual with respect
to such drug was reduced pursuant to
subparagraph (A).
``(4) Reporting requirement.--For purposes of paragraph
(1)(A)(iii), the reporting requirement described in this
paragraph is, with respect to a PBM and any affiliate of such
PBM, that, not later than July 1, 2028, and not less frequently
than annually thereafter, the PBM (or affiliate) submits to the
PDP sponsor and to the Secretary a report containing a
certification that, during the preceding year, such PBM (or
affiliate)--
``(A) complied with the requirements under
paragraphs (2) and (3); and
``(B) did not engage in steering.
``(5) Definitions.--For purposes of this subsection:
``(A) Affiliate.--The term `affiliate' means, with
respect to a PBM or PDP sponsor, an entity that,
directly or indirectly--
``(i) owns, controls, or has an investment
interest in such PBM or PDP sponsor;
``(ii) is owned by such PBM or PDP sponsor
or controlled by such PBM or PDP sponsor;
``(iii) that such PBM or PDP sponsor has an
investment interest in; or
``(iv) is under common ownership or
corporate control of such PBM or PDP sponsor.
``(B) Manufacturer rebate.--The term `manufacturer
rebate'--
``(i) means any price concession (including
any payment, discount, administration fee,
credit, incentive, or penalty) provided by the
manufacturer of a covered part D drug (or any
affiliate, subsidiary, third party, or
intermediary of such manufacturer) to a PDP
sponsor (or any PBM acting on behalf of such
sponsor, including any affiliate of such PBM,
as applicable), in connection with the
furnishing of such covered part D drug to an
individual enrolled in a prescription drug plan
offered by such sponsor; and
``(ii) includes any such price concession
that is determined based upon--
``(I) the aggregate volume of such
covered part D drug (or a group of
covered part D drugs that includes such
part D drug) furnished to individuals
enrolled in a prescription drug plan
offered by such sponsor; or
``(II) the furnishing of any
service provided to the manufacturer by
such sponsor (or any PBM acting on
behalf of such sponsor, or any
affiliate of such PBM (including an
off-shore entity or group purchasing
organization), as applicable) in
connection with the furnishing of such
covered part D drug (or a group of
covered part D drugs that includes such
part D drug).
``(C) Pharmacy benefit manager; pbm.--The terms
`pharmacy benefit manager' and `PBM' mean a person,
business entity, affiliate, or other entity that
performs pharmacy benefits management services.
``(D) Pharmacy benefits management services.--The
term `pharmacy benefits management services'--
``(i) means the managing or administration
of a plan or program that pays for, reimburses,
and covers the cost of prescription drugs and
medical devices; and
``(ii) includes the processing and payment
of claims for prescription drugs and the
adjudication of appeals or grievances related
to qualified prescription drug coverage under
this part.
``(E) Steering.--The term `steering' means, with
respect to a PDP sponsor (and any PBM acting on behalf
of such sponsor, including any affiliate of such PBM,
as applicable)--
``(i) directing, ordering, or requiring an
enrollee in a prescription drug plan to use a
specific pharmacy, including an affiliate
pharmacy, for the purpose of filling a
prescription for a covered part D drug or
receiving services from a pharmacist;
``(ii) offering or implementing a
prescription drug plan design that--
``(I) requires an enrollee in a
prescription drug plan to utilize a
pharmacy, including an affiliate
pharmacy; or
``(II) increases costs to the PDP
sponsor or an enrollee, including by
requiring an enrollee to pay the full
cost for a covered part D drug when
such enrollee chooses not to use an
affiliate pharmacy;
``(iii) advertising, marketing, or
promoting a pharmacy, including an affiliate
pharmacy, in a manner that encourages enrollees
to choose such pharmacy over another in-network
pharmacy;
``(iv) creating more than one network of
pharmacies with respect to a prescription drug
plan such that an in-network pharmacy belonging
to a specific network (such as a preferred
pharmacy network, narrow pharmacy network, or
specialty pharmacy network) receives
preferential treatment, or engaging in any
practice (including accreditation or
credentialing standards, day supply
limitations, or delivery method limitations)
that has the effect of excluding an in-network
pharmacy from participation in the network of
the PDP sponsor or restricting an in-network
pharmacy from filling a prescription for a
covered part D drug; or
``(v) engaging in any practice that
attempts to influence or induce a manufacturer
of a covered part D drug to limit the
distribution of such drug to a small number of
pharmacies or certain types of pharmacies, or
to restrict distribution of such drug to non-
affiliate pharmacies.''.
(2) Requirement to deduct expected rebate amounts from plan
bids.--Section 1860D-11(b)(2)(C) of the Social Security Act (42
U.S.C. 1395w-111(b)(2)(C)) is amended--
(A) in clause (iii), by striking ``and'' at the
end;
(B) by redesignating clause (iv) as clause (v); and
(C) by inserting after clause (iii) the following
new clause:
``(iv) with respect to bids beginning with
plan year 2027, assumptions regarding any
rebate remittance payments provided under
section 1860D-12(h)(3)(B), subtracted from the
actuarial value to produce such bid; and''.
(3) MA-PD plans.--Section 1857(f)(3) of the Social Security
Act (42 U.S.C. 1395w-27(f)(3)) is amended by adding at the end
the following new subparagraph:
``(F) Requirements relating to pharmacy benefit
managers.--For plan years beginning on or after January
1, 2027, section 1860D-12(h).''.
(b) Medicaid.--
(1) In general.--Section 1927 of the Social Security Act
(42 U.S.C. 1396r-8) is amended--
(A) in subsection (e), by adding at the end the
following new paragraph:
``(6) Requirements related to pharmacy benefit managers.--A
contract between the State and a pharmacy benefit manager, or a
contract between the State and a managed care entity or other
specified entity (as such terms are defined in section
1903(m)(9)(D) and collectively referred to in this paragraph as
the `entity') that includes provisions making the entity
responsible for coverage of covered outpatient drugs dispensed
to individuals enrolled with the entity, shall require--
``(A) that the entity or PBM (as applicable) does
not engage in steering;
``(B) that any payment made by the entity or the
PBM (as applicable) for such a drug and related
administrative services (as applicable), including
payments made by a PBM on behalf of the State or
entity, is equal to--
``(i) the ingredient cost of such drug,
which shall be in an amount equal to the sum
of--
``(I) the national average drug
acquisition cost for the drug as of the
day that the pharmacy submits a claim
for payment for such drug (as
determined based upon the retail survey
prices obtained under subsection
(f)(1)), or, in the case of a drug for
which no such national average drug
acquisition cost is available, the
wholesale acquisition cost for such
drug as of such day; and
``(II) an amount equal to 4 percent
of the amount described in item (aa),
or $50, whichever is less; and
``(ii) a dispensing fee that is equal to
the dispensing fee paid for such drug under the
State plan under this title in the State in
which such pharmacy is located, as reported by
the State under subsection (f)(2); and
``(C) that, in the case that the entity or PBM (as
applicable) receives from a manufacturer of a covered
outpatient drug a rebate or discount in connection with
the furnishing of such drug to an individual enrolled
under the State plan (or waiver of such plan), the
entity or PBM remits to the State an amount equal to
the amount of such rebate.''; and
(B) in subsection (k), by adding at the end the
following new paragraphs:
``(13) Pharmacy benefit manager; pbm.--The terms `pharmacy
benefit manager' and `PBM' have the meaning given such terms in
section 1860D-12(h)(C).
``(14) Steering.--The term `steering' has the meaning given
such term in section 1860D-12(h)(E), except that any reference
in such section to the `PDP sponsor' is deemed a reference to a
managed care entity or other specified entity (as such terms
are defined in section 1903(m)(9)(D)) that is responsible for
coverage of covered outpatient drugs, and any reference to a
`covered part D drug' is deemed a reference to a covered
outpatient drug.''.
(2) Conforming amendments.--Section 1903(m) of such Act (42
U.S.C. 1396b(m)) is amended--
(A) in paragraph (2)(A)(xiii)--
(i) by striking ``and (III)'' and inserting
``(III)'';
(ii) by inserting before the period at the
end the following: ``, and (IV) if the contract
includes provisions making the entity
responsible for coverage of covered outpatient
drugs, the entity shall comply with the
requirements of section 1927(e)(6)''; and
(iii) by moving the margin 2 ems to the
left; and
(B) by adding at the end the following new
paragraph:
``(10) No payment shall be made under this title to a State with
respect to expenditures incurred by the State for payment for services
provided by an other specified entity (as defined in paragraph
(9)(D)(iii)) unless such services are provided in accordance with a
contract between the State and such entity which satisfies the
requirements of paragraph (2)(A)(xiii).''.
(3) Effective date.--The amendments made by this subsection
shall apply to contracts between States and managed care
entities, other specified entities, or pharmacy benefit
managers that have an effective date beginning on or after
January 1, 2027.
(c) Penalties for Noncompliant PBMs.--
(1) Criminal penalties.--Section 1128B of the Social
Security Act (42 U.S.C. 1320a-7b) is amended by adding at the
end the following new subsection:
``(i) Whoever provides pharmacy benefits management services on
behalf of a prescription drug plan sponsor under part D of title XVIII
or a medicaid managed care organization under title XIX and--
``(1) knowingly and willfully fails to comply with the
pharmacy payment requirements under section 1860D-12(h)(2) or
section 1927(e)(6)(A), as applicable;
``(2) knowingly and willfully engages in steering (as
defined in section 1860D-12(h)); or
``(3) knowingly and willfully fails to comply with the
rebate pass-through requirements under section 1860D-12(h)(3)
or section 1927(e)(6)(C), as applicable,
shall be guilty of a felony and upon conviction thereof shall be fined
not more than $1,000,000, or imprisoned for not more than 10 years, or
both.''.
(2) Civil monetary penalties.--Section 1128A(a) of the
Social Security Act (42 U.S.C. 1320a-7a(a)) is amended--
(A) in paragraph (10), by adding ``or'' at the end;
(B) by inserting after paragraph (10) the following
new paragraph:
``(11) commits an act described in section 1128B(i);''; and
(C) in the first sentence--
(i) by striking ``or in cases under
paragraph (9)'' and inserting ``in cases under
paragraph (9)''; and
(ii) by striking ``fact)'' and inserting
``fact, or in cases under paragraph (11),
$1,000,000 for each such act)''.
(3) Effective date.--The amendments made by this subsection
shall apply beginning on January 1, 2027.
SEC. 3. IMPROVING PRESCRIPTION DRUG TRANSPARENCY UNDER THE MEDICAID
PROGRAM.
Section 1927(f) of the Social Security Act (42 U.S.C. 1396r-8(f))
is amended--
(1) in the subsection heading, by striking ``Retail'' and
inserting ``covered outpatient drug''; and
(2) in paragraph (1)--
(A) in the paragraph heading, by striking
``retail'' and inserting ``covered outpatient drug'';
(B) in subparagraph (A)(i), by striking ``retail
community pharmacy'' and inserting ``pharmacy that
dispenses covered outpatient drugs, including a retail
community pharmacy, mail-order pharmacy, specialty
pharmacy, nursing home pharmacy, long-term care
facility pharmacy, hospital pharmacy, or clinic
pharmacy (but not including a charitable pharmacy or a
not-for-profit pharmacy)'';
(C) in subparagraph (C)--
(i) in clause (i)--
(I) by striking ``retail''; and
(II) by striking ``prescription''
and inserting ``covered outpatient'';
and
(ii) in clause (ii), by striking ``retail
community'';
(D) in subparagraph (D)(ii), by striking
``retail'';
(E) in subparagraph (E), by striking the term
``retail'' each place it appears; and
(F) by adding at the end the following new
subparagraphs:
``(F) Survey reporting.--In order to meet the
requirement of section 1902(a)(54), a State shall
require that any pharmacy in the State that receives
any payment, reimbursement, administrative fee,
discount, rebate, or other price concession related to
the dispensing of a covered outpatient drug to an
individual receiving benefits under this title,
regardless of whether such payment, reimbursement, fee,
discount, rebate, or other price concession is received
directly from the State or a managed care entity or
other specified entity (as such terms are defined in
section 1903(m)(9)(D)), or is received indirectly from
a pharmacy benefits manager or another entity that has
a contract with the State or a managed care entity or
other specified entity (as so defined)--
``(i) shall respond to surveys conducted
under this paragraph; and
``(ii) shall include in each such response
the pharmacy's acquisition price for each such
drug, net of all such payments, reimbursements,
administrative fees, discounts, rebates, and
other price concessions (or, in the case that
the pharmacy is unable to determine the net
acquisition cost for such a drug at the time
that the survey is received, the pharmacy's
negotiated price for such drug).
``(G) Survey information.--The Secretary shall make
information on national drug acquisition prices
obtained under this paragraph publicly available. Such
information shall include at least the following:
``(i) The monthly response rate to the
survey, including a list of pharmacies not in
compliance with subparagraph (F).
``(ii) The sampling methodology and number
of pharmacies sampled monthly.
``(iii) Information on price concessions to
each pharmacy, including discounts, rebates,
and other price concessions, to the extent that
such information is available during the survey
period.
``(H) Limitation on use of applicable non-retail
pharmacy pricing information.--No State shall use
pricing information reported by a pharmacy that is not
a retail pharmacy to develop or inform reimbursement
rates for retail community pharmacies.''.
<all>
Introduced in House
Introduced in House
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 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.
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