H.R. 6610

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6610 Introduced in House (IH)]

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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.
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