[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), incl