[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[S. 3345 Introduced in Senate (IS)]
<DOC>
119th CONGRESS
1st Session
S. 3345
To amend titles XVIII and XIX of the Social Security Act to ensure
accurate payments to pharmacies under Medicaid and prevent the use of
abusive spread pricing in Medicaid, and to assure pharmacy access and
choice for Medicare beneficiaries and modernize and ensure PBM
accountability under Medicare.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
December 4, 2025
Mr. Crapo (for himself, Mr. Wyden, Mr. Grassley, Mr. Bennet, Mr.
Cornyn, Mr. Warner, Mr. Thune, Mr. Whitehouse, Mr. Cassidy, Ms. Hassan,
Mr. Lankford, Ms. Cortez Masto, Mr. Daines, Ms. Smith, Mr. Barrasso,
Mr. Lujan, Mr. Tillis, Mr. Warnock, Mrs. Blackburn, Mr. Welch, and Mr.
Marshall) introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To amend titles XVIII and XIX of the Social Security Act to ensure
accurate payments to pharmacies under Medicaid and prevent the use of
abusive spread pricing in Medicaid, and to assure pharmacy access and
choice for Medicare beneficiaries and modernize and ensure PBM
accountability under Medicare.
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 ``PBM Price Transparency and
Accountability Act''.
SEC. 2. ENSURING ACCURATE PAYMENTS TO PHARMACIES UNDER MEDICAID AND
PREVENTING THE USE OF ABUSIVE SPREAD PRICING IN MEDICAID.
(a) Ensuring Accurate Payments to Pharmacies Under Medicaid.--
(1) In general.--Section 1927(f) of the Social Security Act
(42 U.S.C. 1396r-8(f)) is amended--
(A) in paragraph (1)(A)--
(i) by redesignating clause (ii) as clause
(iii); and
(ii) by striking ``and'' after the
semicolon at the end of clause (i) and all that
precedes it through ``(1)'' and inserting the
following:
``(1) Determining pharmacy actual acquisition costs.--The
Secretary shall conduct a survey of retail community pharmacy
drug prices and applicable non-retail pharmacy drug prices to
determine national average drug acquisition cost benchmarks (as
such term is defined by the Secretary) as follows:
``(A) Use of vendor.--The Secretary may contract
services for--
``(i) with respect to retail community
pharmacies, the determination of retail survey
prices of the national average drug acquisition
cost for covered outpatient drugs that
represent a nationwide average of consumer
purchase prices for such drugs, net of all
discounts, rebates, and other price concessions
(to the extent any information with respect to
such discounts, rebates, and other price
concessions is available) based on a monthly
survey of such pharmacies;
``(ii) with respect to applicable non-
retail pharmacies--
``(I) the determination of survey
prices, separate from the survey prices
described in clause (i), of the non-
retail national average drug
acquisition cost for covered outpatient
drugs that represent a nationwide
average of consumer purchase prices for
such drugs, net of all discounts,
rebates, and other price concessions
(to the extent any information with
respect to such discounts, rebates, and
other price concessions is available)
based on a monthly survey of such
pharmacies; and
``(II) at the discretion of the
Secretary, for each type of applicable
non-retail pharmacy, the determination
of survey prices, separate from the
survey prices described in clause (i)
or subclause (I) of this clause, of the
national average drug acquisition cost
for such type of pharmacy for covered
outpatient drugs that represent a
nationwide average of consumer purchase
prices for such drugs, net of all
discounts, rebates, and other price
concessions (to the extent any
information with respect to such
discounts, rebates, and other price
concessions is available) based on a
monthly survey of such pharmacies;
and'';
(B) in subparagraph (B) of paragraph (1), by
striking ``subparagraph (A)(ii)'' and inserting
``subparagraph (A)(iii)'';
(C) in subparagraph (D) of paragraph (1), by
striking clauses (ii) and (iii) and inserting the
following:
``(ii) The vendor must update the Secretary
no less often than monthly on the survey prices
for covered outpatient drugs.
``(iii) The vendor must differentiate, in
collecting and reporting survey data, for all
cost information collected, whether a pharmacy
is a retail community pharmacy or an applicable
non-retail pharmacy, including whether such
pharmacy is an affiliate (as defined in
subsection (k)(13)), and, in the case of an
applicable non-retail pharmacy, which type of
applicable non-retail pharmacy it is using the
relevant pharmacy type indicators included in
the guidance required by subsection (a)(4)(A)
of section 2 of the PBM Price Transparency and
Accountability Act.'';
(D) by adding at the end of paragraph (1) the
following:
``(F) Survey reporting.--In order to meet the
requirement of section 1902(a)(54), a State shall
require that any retail community pharmacy or
applicable non-retail pharmacy in the State that
receives any payment, reimbursement, administrative
fee, discount, rebate, or other price concession
related to the dispensing of covered outpatient drugs
to individuals receiving benefits under this title,
regardless of whether such payment, reimbursement,
administrative fee, discount, rebate, or other price
concession is received from the State or a managed care
entity or other specified entity (as such terms are
defined in section 1903(m)(9)(D)) directly or from a
pharmacy benefit manager or another entity that has a
contract with the State or a managed care entity or
other specified entity (as so defined), shall respond
to surveys conducted under this paragraph.
``(G) Survey information.--Information on national
drug acquisition prices obtained under this paragraph
shall be made publicly available in a form and manner
to be determined by the Secretary and 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
pharmacies, including discounts, rebates, and
other price concessions, to the extent that
such information may be publicly released and
has been collected by the Secretary as part of
the survey.
``(H) Penalties.--
``(i) In general.--Subject to clauses (ii),
(iii), and (iv), the Secretary shall enforce
the provisions of this paragraph with respect
to a pharmacy through the establishment of
civil money penalties applicable to a retail
community pharmacy or an applicable non-retail
pharmacy.
``(ii) Basis for penalties.--The Secretary
shall impose a civil money penalty established
under this subparagraph on a retail community
pharmacy or applicable non-retail pharmacy if--
``(I) the retail pharmacy or
applicable non-retail pharmacy refuses
or otherwise fails to respond to a
request for information about prices in
connection with a survey under this
subsection;
``(II) knowingly provides false
information in response to such a
survey; or
``(III) otherwise fails to comply
with the requirements established under
this paragraph.
``(iii) Parameters for penalties.--
``(I) In general.--A civil money
penalty established under this
subparagraph may be assessed with
respect to each violation, and with
respect to each non-compliant retail
community pharmacy (including a
pharmacy that is part of a chain) or
non-compliant applicable non-retail
pharmacy (including a pharmacy that is
part of a chain), in an amount not to
exceed $100,000 for each such
violation.
``(II) Considerations.--In
determining the amount of a civil money
penalty imposed under this
subparagraph, the Secretary may
consider the size, business structure,
and type of pharmacy involved, as well
as the type of violation and other
relevant factors, as determined
appropriate by the Secretary.
``(iv) Rule of application.--The provisions
of section 1128A (other than subsections (a)
and (b)) shall apply to a civil money penalty
under this subparagraph in the same manner as
such provisions apply to a civil money penalty
or proceeding under section 1128A(a).
``(I) Limitation on use of applicable non-retail
pharmacy pricing information.--No State shall use
pricing information reported by applicable non-retail
pharmacies under subparagraph (A)(ii) to develop or
inform payment methodologies for retail community
pharmacies.'';
(E) in paragraph (2)--
(i) in subparagraph (A), by inserting ``,
including payment rates and methodologies for
determining ingredient cost reimbursement under
managed care entities or other specified
entities (as such terms are defined in section
1903(m)(9)(D)),'' after ``under this title'';
and
(ii) in subparagraph (B), by inserting
``and the basis for such dispensing fees''
before the semicolon;
(F) by redesignating paragraph (4) as paragraph
(5);
(G) by inserting after paragraph (3) the following
new paragraph:
``(4) Oversight.--
``(A) In general.--The Inspector General of the
Department of Health and Human Services shall conduct
periodic studies of the survey data reported under this
subsection, as appropriate, including with respect to
substantial variations in acquisition costs or other
applicable costs, as well as with respect to how
internal transfer prices and related party transactions
may influence the costs reported by pharmacies that are
affiliates (as defined in subsection (k)(13)) or are
owned by, controlled by, or related under a common
ownership structure with a wholesaler, distributor, or
other entity that acquires covered outpatient drugs
relative to costs reported by pharmacies not affiliated
with such entities. The Inspector General shall provide
periodic updates to Congress on the results of such
studies, as appropriate, in a manner that does not
disclose trade secrets or other proprietary
information.
``(B) Appropriation.--There is appropriated to the
Inspector General of the Department of Health and Human
Services, out of any money in the Treasury not
otherwise appropriated, $5,000,000 for fiscal year
2026, to remain available until expended, to carry out
this paragraph.''; and
(H) in paragraph (5), as so redesignated--
(i) by inserting ``, and $9,000,000 for
fiscal year 2026 and each fiscal year
thereafter,'' after ``2010''; and
(ii) by inserting ``Funds appropriated
under this paragraph for fiscal year 2026 and
any subsequent fiscal year shall remain
available until expended.'' after the period.
(2) Definitions.--Section 1927(k) of the Social Security
Act (42 U.S.C. 1396r-8(k)) is amended--
(A) in the matter preceding paragraph (1), by
striking ``In the section'' and inserting ``In this
section''; and
(B) by adding at the end the following new
paragraphs:
``(12) Applicable non-retail pharmacy.--The term
`applicable non-retail pharmacy' means a pharmacy that is
licensed as a pharmacy by the State and that is not a retail
community pharmacy, including a pharmacy that dispenses
prescription medications to patients primarily through mail and
specialty pharmacies. Such term does not include nursing home
pharmacies, long-term care facility pharmacies, hospital
pharmacies, clinics, charitable or not-for-profit pharmacies,
government pharmacies, or low dispensing pharmacies (as defined
by the Secretary).
``(13) Affiliate.--The term `affiliate' means any entity
that is owned by, controlled by, or related under a common
ownership structure with a pharmacy benefit manager or a
managed care entity or other specified entity (as such terms
are defined in section 1903(m)(9)(D)).''.
(3) Effective date.--
(A) In general.--Subject to subparagraph (B), the
amendments made by this subsection shall take effect on
the first day of the first quarter that begins on or
after the date that is 6 months after the date of
enactment of this Act.
(B) Delayed application to applicable non-retail
pharmacies.--The pharmacy survey requirements
established by the amendments to section 1927(f) of the
Social Security Act (42 U.S.C. 1396r-8(f)) made by this
subsection shall apply to retail community pharmacies
beginning on the effective date described in
subparagraph (A), but shall not apply to applicable
non-retail pharmacies until the first day of the first
quarter that begins on or after the date that is 18
months after the date of enactment of this Act.
(4) Identification of applicable non-retail pharmacies.--
(A) In general.--Not later than January 1, 2027,
the Secretary of Health and Human Services shall, in
consultation with stakeholders as appropriate, publish
guidance specifying pharmacies that meet the definition
of applicable non-retail pharmacies (as such term is
defined in subsection (k)(12) of section 1927 of the
Social Security Act (42 U.S.C. 1396r-8), as added by
paragraph (2)), and that will be subject to the survey
requirements under subsection (f)(1) of such section,
as amended by paragraph (1).
(B) Inclusion of pharmacy type indicators.--The
guidance published under subparagraph (A) shall include
pharmacy type indicators to distinguish between
different types of applicable non-retail pharmacies,