No official summary available for this bill.
[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6610 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 6610
To amend chapter 89 of title 5, United States Code, to limit the costs
of pharmacy benefit managers with respect to Federal employee health
benefit plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 11, 2025
Mr. Auchincloss (for himself, Mr. Comer, Mrs. Harshbarger, Mr. Carter
of Georgia, Mr. Ciscomani, Mr. Moulton, Mr. Deluzio, Ms. Tlaib, Ms.
Budzinski, Mr. Krishnamoorthi, Mr. Khanna, 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 Oversight and Government Reform
_______________________________________________________________________
A BILL
To amend chapter 89 of title 5, United States Code, to limit the costs
of pharmacy benefit managers with respect to Federal employee health
benefit plans, 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 ``Pharmacists Fight Back [in Federal
Employee Health Benefit Plans Act]''.
SEC. 2. PHARMACY PAYMENT AND REIMBURSEMENT REQUIREMENTS.
(a) In General.--Section 8904 of title 5, United States Code, is
amended by adding at the end the following new subsection:
``(c)(1) The Office of Personnel Management may not contract for or
approve a health benefits plan under section 8903 of this title unless
such plan--
``(A) requires any pharmacy benefits manager
administering prescription drug benefits on behalf of
such health benefits plan, either directly or through
an affiliate of such pharmacy benefits manager, to--
``(i) reimburse an in-network pharmacy for
the ingredient cost of a prescription drug in
an amount equal to the sum of--
``(I) the national average drug
acquisition cost for the drug on the
day of claim adjudication (or, in the
case of a drug that does not appear on
the national average drug acquisition
cost index, the wholesale acquisition
cost for such prescription drug); and
``(II) the lesser of the amount
that is equal to 4 percent of the
amount described in subclause (I) or
$50;
``(ii) pay an in-network pharmacy a
professional dispensing fee that is equal to
the professional dispensing fee paid by the
State in which the pharmacy is located under
title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) for dispensing a prescription
drug; and
``(iii) for any manufacturer rebate such
pharmacy benefits manager or affiliate thereof
receives in connection with a drug obtained at
an in-network pharmacy by an individual
pursuant to such prescription drug benefits,
such pharmacy benefits manager or affiliate
shall--
``(I) apply, 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 the net cost of the
drug, including such rebate; and
``(II) remit to the carrier for
such health benefits plan an amount
equal to the amount of such rebate,
less the amount by which the
coinsurance or copayment owed by such
individual with respect to such drug
was reduced under subclause (I);
``(B) prohibits such pharmacy benefits manager and
any affiliate thereof from--
``(i) directing, ordering, or requiring an
individual enrolled in such health benefits
plan to use a specific pharmacy, including a
pharmacy that is an affiliate of such pharmacy
benefits manager, for the purpose of filling a
prescription for a prescription drug or
receiving services;
``(ii) advertising, marketing, or promoting
a specific pharmacy, including a pharmacy that
is an affiliate of such pharmacy benefits
manager, over another in-network pharmacy;
``(iii) creating any network or engaging in
any practice, including accreditation or
credentialing standards, day supply
limitations, or delivery method limitations,
that excludes an in-network pharmacy or
restricts an in-network pharmacy from filling a
prescription for a prescription drug for which
benefits are available under such health
benefits plan;
``(iv) directly or indirectly engaging in
any practice that attempts to influence or
induce a pharmaceutical manufacturer to limit
the distribution of a prescription drug to a
small number of pharmacies or certain types of
pharmacies, or to restrict distribution of such
drug to non-affiliate pharmacies; or
``(v) requiring an individual enrolled in
such health benefits plan to reimburse the
pharmacy benefits manager or affiliate for the
dispensing fee paid to an in-network pharmacy
pursuant to subparagraph (A)(ii) with respect
to a prescription drug obtained at such
pharmacy by such individual, or otherwise
increasing the amount owed by such individual
with respect to such drug to account for such
dispensing fee;
``(C) prohibits any such pharmacy benefits manager
from lowering, imposing a fee on, or otherwise make any
adjustment to a prescription drug claim at the time the
claim for such drug is adjudicated or after the claim
is adjudicated that reduces the amount a pharmacy is
reimbursed for such drug pursuant to subparagraph (A),
including by charging any fee to such pharmacy that is
not associated with a prescription drug claim; and
``(D) requires the carrier providing such health
benefits plan to cooperate with any inspection of such
carrier carried out under section 8902b(a)(3)(B) of
this title, including by making available to the Office
such documents, personnel, and facilities of the
carrier as and when determined necessary to Office to
carry out such inspection.
``(2) In this subsection:
``(A) The term `affiliate' means an entity, including a
pharmacy, that directly or indirectly through one or more
intermediaries--
``(i) owns, in whole or in part, or controls a
pharmacy benefits manager;
``(ii) is owned, in whole or in part, or controlled
by that is a pharmacy benefits manager; or
``(iii) is a subsidiary of or owned, in whole or in
part, or controlled by an entity that owns or controls
a pharmacy benefits manager.
``(B) The term `beneficiary' means a person who receives
prescription drug benefits under a health benefits plan.
``(C) The term `in-network pharmacy' means a pharmacy that
is licensed by the State board of pharmacy in the State in
which such pharmacy is located, that fills or seeks to fill a
prescription for a prescription drug for a beneficiary, and is
not barred from participating in the program under this chapter
under section 8902a.
``(D) The term `pharmacy benefits manager' means a person,
business entity, affiliate, or other entity that performs
pharmacy benefits management services.
``(E) 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 the prescription drug
benefit.
``(F) The term `prescription drug' means a prescription
drug covered by a health benefits plan that is dispensed to a
beneficiary for self-administration.''.
(b) Noncompliance Penalties.--
(1) In general.--Chapter 89 of title 5, United States Code,
is amended by inserting after section 8902a the following new
section:
``Sec. 8902b. Pharmacy benefit manager-related sanctions
``(a) Monetary Penalties.--
``(1) In general.--Except as otherwise provided by this
subsection and subsection (c), if the Office of Personnel
Management determines that a pharmacy benefits manager violated
a requirement or prohibition applicable to such pharmacy
benefits manager with respect to a health benefits plan
pursuant to section 8904(c)(1) of this title, the Office shall,
in addition to any other penalties that may be prescribed by
law and after consultation with the Attorney General, impose a
civil monetary penalty of $10,000 for each such violation--
``(A) on such pharmacy benefits manager; and
``(B) if, during the 10-year period ending on the
imposition of such civil monetary penalty, not fewer
than five civil monetary penalties have been imposed on
such pharmacy benefits manager under this paragraph
with respect to health benefit plans provided by the
carrier providing such health benefits plan, on such
carrier.
``(2) Maximum penalty amount.--
``(A) Pharmacy benefit managers.--For each carrier
providing a health benefits plan with respect to which
a pharmacy benefits manager is determined to have
committed a violation described in paragraph (1), the
total amount of civil monetary penalties imposed on
such pharmacy benefits manager under such paragraph for
violations with respect to the health benefit plans of
such carrier many not exceed $100,000 during any 10-
year period.
``(B) Carriers.--The total amount of civil monetary
penalties imposed on a carrier under paragraph (1) may
not exceed $50,000 during any 10-year period.
``(3) Remediation plan.--
``(A) In general.--Not later than 60 days after the
date on which the Office of Personnel Management
imposes a civil monetary penalty on a carrier under
paragraph (1) with respect to a pharmacy benefits
manager that is the fifth such civil monetary penalty
imposed on such carrier with respect to such pharmacy
benefits manager in a 10-year period, such carrier
shall develop and submit to the Office of Personnel
Management a plan to ensure that each pharmacy benefit
manager administering prescription drug benefits on
behalf of a health benefits plan provided by such
carrier complies with the requirements and prohibitions
applicable to such pharmacy benefit manager pursuant to
section 8904(c)(1).
``(B) Oversight.--Not later than 60 days after the
date on which a carrier submits plan under subparagraph
(A), and with such frequency thereafter as determined
appropriate by the Office of Personnel Management, the
Office of Personnel Management shall inspect such
carrier to assess the compliance of such carrier with
such plan.
``(4) Sequential imposition.--For the purposes of this
subsection, any civil monetary penalties concurrently imposed
under paragraph (1) shall be deemed to be imposed sequentially.
``(5) Civil action.--
``(A) In general.--A civil action to recover a
civil monetary penalty imposed under this subsection
shall be brought by the Attorney General in the name of
the United States, and may be brought in the United
States district court for the district where the claim
involved was presented or where the pharmacy benefits
manager or carrier subject to such civil monetary
penalty resides.
``(B) Treatment of amounts recovered.--Amounts
recovered under this subsection shall be paid to the
Office of Personnel Management for deposit into the
Employees Health Benefits Fund.
``(6) Deduction from amounts owed.--The amount of a civil
monetary penalty imposed under this subsection may be deducted
from any sum then or later owing by the United States to the
party against whom the penalty or assessment has been levied.
``(7) Statute of limitations.--The Office of Personnel
Management may not initiate any action to impose a civil
monetary penalty on a pharmacy benefits manager or carrier
under this subsection later than 6 years after the date of the
violation of the requirement or prohibition by the pharmacy
benefits manager for which such civil monetary penalty would be
imposed.
``(b) Debarment.--
``(1) In general.--The Office of Personnel Management shall
bar a pharmacy benefits manager from administering prescription
drug benefits on behalf of a health benefits plan, either
directly of through an affiliate of such pharmacy benefits
manager, under the program under this chapter if, in any 10-
year period, the Office of Personnel Management imposes 10 or
more civil monetary penalties on such pharmacy benefits manager
under subsection (a).
``(2) Effective date.--Except as provided by subsection
(c), debarment of a pharmacy benefits manager under paragraph
(1) shall be effective on the date that is 90 days after the
date on which the Office of Personnel Management imposes the
first civil monetary penalty pursuant to which such pharmacy
benefits manager is subject to such debarment.
``(3) Payment prohibited.--
``(A) In general.--Notwithstanding section 8902(j)
or any other provision of this chapter, if, under this
section a pharmacy benefits manager is debarred under
paragraph (1), no payment may be made by a carrier
pursuant to any contract under this chapter (either to
such pharmacy benefits manager or by reimbursement) for
any service or supply furnished by such pharmacy
benefits manager during the period of the debarment.
``(B) Subcontract contracts.--Each contract under
this chapter shall contain such provisions as may be
necessary to carry out subparagraph (A) and the other
provisions of this section.
``(4) Termination.--The debarment of a pharmacy benefits
manager under paragraph (1) shall be immediately terminated if
all civil monetary penalties pursuant to which such pharmacy
benefits manager is subject to such debarment are overturned or
wholly set aside on appeal.
``(5) Rule of construction.--For the purposes of this
subsection, a civil monetary penalty is a civil monetary
penalty pursuant to which a pharmacy benefits manager is
subject to debarment under paragraph (1) if such civil monetary
penalty is not less than the tenth civil monetary penalty
imposed on such pharmacy benefits manager under subsection (a)
during a 10-year period that--
``(A) has not been appealed and for which the
period of appeal has elapsed; or
``(B) has been appealed, all appeals have been
exhausted, and has not be overturned or wholly set
aside.
``(c) Hearing.--
``(1) In general.--The Office of Personnel Management shall
not make a determination adverse to a pharmacy benefits manager
or carrier under subsection (a) or a determination adverse to a
pharmacy benefits manager (b) until such pharmacy benefits
manager or carrier, as applicable, has been given reasonable
notice and an opportunity for the determination to be made
after a hearing as provided in accordance with this subsection.
``(2) Hearing required.--Any pharmacy benefits manager or
carrier that is the subject of an adverse determination by the
Office of Personnel Management under this section shall be
entitled to reasonable notice and an opportunity to request a
hearing on the record, and to judicial review as provided in
this subsection after the Office of Personnel Management makes
a final decision regarding such adverse determination.
``(3) Hearing criteria.--The Office of Personnel Management
shall grant a request for a hearing under paragraph (2) upon a
showing that due process rights have not previously been
afforded with respect to any finding of fact which is relied
upon as a cause for an adverse determination under this
section. Such hearing shall be conducted without regard to
subchapter II of chapter 5 and chapter 7 of this title by a
hearing officer who shall be designated by the Director of the
Office of Personnel Management and who shall not otherwise have
been involved in the adverse determination being appealed.
``(4) Request for hearing.--A request for a hearing under
paragraph (2) shall be filed within such period and in
accordance with such procedures as the Office of Personnel
Management shall prescribe by regulation.
``(5) Appeal.--
``(A) In general.--Any pharmacy benefits manager or
carrier adversely affected by a final decision of the
Office of Personnel Management regarding an adverse
determination that is made after a hearing under
paragraph (2) with respect to such adverse
determination and to which such pharmacy benefits
manager or carrier was a party may seek review of such
final decision in the United States District Court for
the District of Columbia or for the district in which
the pharmacy benefits manager or carrier resides or has
his or her principal place of business by filing a
notice of appeal in such court within 60 days after the
date the decision is issued, and by simultaneously
sending copies of such notice by certified mail to the
Director of the Office and to the Attorney General.
``(B) Answer.--In answer to an appeal filed under
subparagraph (A), the Director of the Office of
Personnel Management shall promptly file in the
relevant court a certified copy of the transcript of
the record of the hearing conducted under paragraph (2)
and other evidence upon which the findings and final
decision complained of are based.
``(C) Court authority.--With respect to an appeal
filed under subparagraph (A), the court shall have
power to enter, upon the pleadings and evidence of
record, a judgment affirming, modifying, or setting
aside, in whole or in part, the final decision of the
Office of Personnel Management that is the subject of
such appeal, with or without remanding the case for a
rehearing. The court shall not set aside or remand such
final decision unless there is not substantial evidence
on the record, taken as whole, to support the such
final decision or unless the actions of the Office of
Personnel Management with respect to such final
decision constitutes an abuse of discretion.
``(6) Defense forfeiture.--Matters that were raised or that
could have been raised in a hearing under paragraph (2) or an
appeal under paragraph (5) may not be raised as a defense to a
civil action by the United States to collect a civil monetary
penalty imposed under subsection (a).
``(d) Affiliate; Pharmacy Benefits Manager; Prescription Drug
Defined.--In this section, the terms `affiliate', `pharmacy benefits
manager' and `prescription drug' have the meanings given such terms,
respectively, in section 8904(c) of this title.''.
(2) Clerical amendment.--The table of sections for chapter
89 of title 5, United States Code, is amended by inserting
after the item relating to section 8902a the following new
item:
``8902b. Pharmacy benefit manager-related sanctions.''.
(c) Conforming Amendment.--Section 8903a(b) of title 5, United
States Code, is amended--
(1) in paragraph (3), by striking ``and'' at the end;
(2) in paragraph (4), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following new paragraph:
``(5) complies with the requirements under section
8904(c).''.
(d) Effective Date.--The amendments made by this Act shall take
effect on the date that is one year after the date of the enactment of
this Act.
<all>
Introduced in House
Introduced in House
Referred to the House Committee on Oversight and Government Reform.
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