[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1035 Introduced in House (IH)]
<DOC>
116th CONGRESS
1st Session
H. R. 1035
To amend title XVIII of the Social Security Act to provide for pharmacy
benefits manager standards under the Medicare prescription drug program
and Medicare Advantage program to further transparency of payment
methodologies to pharmacies, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
February 7, 2019
Mr. Collins of Georgia (for himself, Mr. Loebsack, Mr. David P. Roe of
Tennessee, Mr. Westerman, Miss Rice of New York, Mr. King of Iowa, Ms.
Clarke of New York, Mr. Austin Scott of Georgia, Mr. Hice of Georgia,
Mr. Vela, Mr. Raskin, Mrs. Rodgers of Washington, Mr. Welch, Mr. Carter
of Georgia, Mr. Crawford, Mr. Peterson, and Mr. Byrne) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Ways and Means, and
Oversight and Reform, 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 title XVIII of the Social Security Act to provide for pharmacy
benefits manager standards under the Medicare prescription drug program
and Medicare Advantage program to further transparency of payment
methodologies to pharmacies, 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 ``Prescription Drug Price Transparency
Act''.
SEC. 2. PHARMACY BENEFITS MANAGER STANDARDS UNDER THE MEDICARE PROGRAM
FOR PRESCRIPTION DRUG PLANS AND MA-PD PLANS.
(a) In General.--Section 1860D-12(b) of the Social Security Act (42
U.S.C. 1395w-112(b)) is amended by adding at the end the following new
paragraph:
``(8) Pharmacy benefits manager transparency
requirements.--Each contract entered into with a PDP sponsor
under this part with respect to a prescription drug plan
offered by such sponsor or with an MA organization offering an
MA-PD plan under part C shall provide that the sponsor or
organization, respectively, may not enter into a contract with
any pharmacy benefits manager (referred to in this paragraph as
a `PBM') to manage the prescription drug coverage provided
under such plan, or to control the costs of the prescription
drug coverage under such plan, if the PBM--
``(A) requires that a plan enrollee use a retail
pharmacy, mail order pharmacy, specialty pharmacy, or
other pharmacy entity providing pharmacy services in
which the PBM has an ownership interest or that has an
ownership interest in the PBM; or
``(B) provides an incentive (including a reduced
copayment or coinsurance) to a plan enrollee to
encourage the enrollee to use a retail pharmacy, mail
order pharmacy, specialty pharmacy, or other pharmacy
entity providing pharmacy services in which the PBM has
an ownership interest or that has an ownership interest
in the PBM, if the incentive is applicable only to such
pharmacies.''.
(b) Regular Update of Prescription Drug Pricing Standard.--
Paragraph (6) of section 1860D-12(b) of the Social Security Act (42
U.S.C. 1395w-112(b)) is amended to read as follows:
``(6) Regular update of prescription drug pricing
standard.--
``(A) In general.--If the PDP sponsor of a
prescription drug plan (or MA organization offering an
MA-PD plan) uses a standard for reimbursement (as
described in subparagraph (B)) of pharmacies based on
the cost of a drug, each contract entered into with
such sponsor under this part (or organization under
part C) with respect to the plan shall provide that the
sponsor (or organization) shall--
``(i) update such standard not less
frequently than once every 7 days, beginning
with an initial update on January 1 of each
year, to accurately reflect the market price of
acquiring the drug;
``(ii) disclose to applicable pharmacies
and the respective contracting entities of such
pharmacies the sources used for making any such
update immediately without requirement of
request;
``(iii) if the source for such a standard
for reimbursement is not publicly available,
disclose to the applicable pharmacies and the
respective contracting entities of such
pharmacies all individual drug prices to be so
updated in advance of the use of such prices
for the reimbursement of claims;
``(iv) establish a process for applicable
pharmacies and respective contracting entities
to appeal, investigate, and resolve disputes
regarding individual drug prices that are less
than the pharmacy acquisition price for such
drug, which must be adjudicated within 7 days
of the pharmacy filing its appeal; and
``(v) provide to applicable pharmacies and
respective contracting entities all such
pricing data in an .xml spreadsheet format or a
comparable easily accessible and complete
spreadsheet format.
``(B) Prescription drug pricing standard defined.--
For purposes of subparagraph (A), a standard for
reimbursement of a pharmacy is any methodology or
formula for varying the pricing of a drug or drugs
during the term of the pharmacy reimbursement contract
that is based on the cost of the drug involved,
including drug pricing references and amounts that are
based upon average wholesale price, wholesale average
cost, average manufacturer price, average sales price,
maximum allowable cost (MAC), or other costs, whether
publicly available or not.''.
(c) Effective Date.--The amendments made by this section shall
apply to plan years beginning on or after January 1, 2020.
SEC. 3. PRESCRIPTION DRUG TRANSPARENCY IN THE FEDERAL EMPLOYEES HEALTH
BENEFITS PROGRAM.
(a) In General.--Section 8902 of title 5, United States Code, is
amended by adding at the end the following new subsections:
``(p) A contract may not be made or a plan approved under this
chapter under which a carrier has an agreement with a pharmacy benefits
manager (in this subsection referred to as a `PBM') to manage
prescription drug coverage or to control the costs of the prescription
drug coverage if the PBM--
``(1) requires that an individual enrolled under such
contract or plan use a retail pharmacy, mail order pharmacy,
specialty pharmacy, or other pharmacy entity providing pharmacy
services in which the PBM has an ownership interest or that has
an ownership interest in the PBM; or
``(2) provides an incentive (including a reduced copayment
or coinsurance) to a plan enrollee to encourage the enrollee to
use a retail pharmacy, mail order pharmacy, specialty pharmacy,
or other pharmacy entity providing pharmacy services in which
the PBM has an ownership interest or that has an ownership
interest in the PBM, if the incentive is applicable only to
such pharmacies.
``(q)(1) If a contract made or plan approved under this chapter
provides for a standard for reimbursement (as described in paragraph
(2)) with respect to a prescription drug plan, such contract or plan
shall provide that the applicable carrier--
``(A) update such standard not less frequently than once
every 7 days, beginning with an initial update on January 1 of
each year, to accurately reflect the market price of acquiring
the drug;
``(B) disclose to applicable pharmacies and the respective
contracting entities of such pharmacies the sources used for
making any such update immediately without requirement of
request;
``(C) if the source for such a standard for reimbursement
is not publicly available, disclose to the applicable
pharmacies and respective contracting entities of such
pharmacies all individual drug prices to be so updated in
advance of the use of such prices for the reimbursement of
claims;
``(D) establish a process for applicable pharmacies and
respective contracting entities to appeal, investigate, and
resolve disputes regarding individual drug prices that are less
than the pharmacy acquisition price for such drug, which must
be adjudicated within 7 days of the pharmacy filing its appeal;
and
``(E) provide to applicable pharmacies and respective
contracting entities all such pricing data in an .xml
spreadsheet format or a comparable easily accessible and
complete spreadsheet format.
``(2) For purposes of paragraph (1), a standard for reimbursement
of a pharmacy is any methodology or formula for varying the pricing of
a drug or drugs during the term of the pharmacy reimbursement contract
that is based on the cost of the drug involved, including drug pricing
references and amounts that are based upon average wholesale price,
wholesale average cost, average manufacturer price, average sales
price, maximum allowable cost, or other costs, whether publicly
available or not.''.
(b) Application.--The amendment made by subsection (a) shall apply
to any contract entered into under section 8902 of title 5, United
States Code, on or after the date of enactment of this section.
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Prescription Drug Price Transparency Act
#1035 | HR Congress #116
Policy Area: Health
Last Action: Referred to the Subcommittee on Health. (2/7/2019)
Bill Text Source: Congress.gov
Summary and Impacts
Original Text