H.R. 6609

[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>