Protect Beneficiaries from Middlemen Act
Officially: “Protect Beneficiaries from Middlemen Act” Read the full text
What it does
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1Short title
This section would state that the Act may be cited as the "Protect Beneficiaries from Middlemen Act."
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1. Short title This Act may be cited as the Protect Beneficiaries from Middlemen Act .
2Limitation on cost sharing to net price amount under Medicare part D
This section would amend section 1860D-2 of the Social Security Act to add a new limit on what Medicare Part D beneficiaries can be charged for a drug. Starting with plan years beginning on or after January 1, 2027, for costs above the deductible and before a beneficiary reaches the annual out-of-pocket spending threshold, a Part D plan's cost sharing for a month's supply of a covered drug dispensed by a pharmacy could not exceed the average net price for that supply of the drug during the plan year, or, if lower, the cash price the same pharmacy would charge someone who had no benefits for the drug under a federal health care program, a group or individual health plan, or the federal employee health benefits program under chapter 89 of title 5, United States Code. The average net price would be defined, for a given drug, plan, and plan year, as the average amount actually paid for a dispensed supply during that year (counting any amount the beneficiary paid as cost sharing), minus any rebates or other remuneration the plan received tied to that drug. This section would also revise two existing cross-references in the same subsection: paragraph (2)(A) would be revised to add a reference to the new paragraph (10) alongside its existing references to paragraphs (8) and (9), and paragraph (9)(B)(ii) would be revised so that its rule applies subject to the new paragraph (10). It would further provide that a plan's drug coverage counts as qualified coverage under subsection (c) only if it complies with the new net-price limit. Separately, this section would amend section 1860D-14(a)(1)(D)(iii) of the Social Security Act so that, for plan year 2027 and later, the copayment charged to a low-income subsidy-eligible individual for a covered Part D drug could not exceed the same net-price cap. Finally, by January 1, 2029, the Comptroller General of the United States would have to submit a report to Congress analyzing compliance with and enforcement of these amendments, and making recommendations for improving that enforcement and for improving public disclosure and public awareness of the requirements.
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2. Limitation on cost sharing to net price amount under Medicare part D (a) In general Section 1860D–2 of the Social Security Act ( 42 U.S.C. 1395w–102 ) is amended— (1) in subsection (b)— (A) in paragraph (2)(A), by striking (8) and (9) and inserting (8), (9), and (10) ; (B) in paragraph (9)(B)(ii), by striking For a plan year and inserting Subject to paragraph (10), for a plan year ; and (C) by adding at the end the following new paragraph: (10) Limitation on cost sharing to net price amount (A) In general For a plan year beginning on or after January 1, 2027, the coverage provides benefits for a supply of a covered part D drug dispensed by a pharmacy, for costs in excess of the deductible specified in paragraph (1) and prior to an individual reaching the out-of-pocket threshold under paragraph (4), with cost-sharing for a month’s supply that does not exceed the average net price for such a supply of such drug during such plan year (or, if lower, the applicable cash price for such a supply of such drug so dispensed by such pharmacy). (B) Definitions In this paragraph: (i) Applicable cash price The term applicable cash price means, with respect to a supply of a covered part D drug dispensed by a pharmacy, the price that such pharmacy would charge for such supply of such drug dispensed to an individual without benefits for such drug under any Federal health care program (as defined in section 1128B), a group health plan or group or individual health insurance coverage (as such terms are defined in section 2791 of the Public Health Service Act), or the program established under chapter 89 of title 5, United States Code. (ii) Average net price The term average net price means, with respect to a supply of a covered part D drug, a prescription drug plan, and a plan year, the average amount paid under such plan (including any amounts paid by an individual enrolled under such plan as cost sharing for such drug) as payment for such a supply of such drug dispensed during such year, less any rebates or other forms of remuneration received under such plan with respect to such drug. ; and (2) in subsection (c), by adding at the end the following new paragraph: (7) Cost sharing limited to net price The coverage is provided in accordance with subsection (b)(10). . (b) Conforming amendment to cost-Sharing for low-Income individuals Section 1860D–14(a)(1)(D)(iii) of the Social Security Act ( 42 U.S.C. 1395w–114(a)(1)(D)(iii) ) is amended by adding at the end the following new sentence: For plan year 2027 and subsequent plan years, the copayment amount applicable under this clause to a supply of a covered part D drug dispensed to the individual may not exceed the amount provided under section 1860D–2(b)(10). . (c) GAO report Not later than January 1, 2029, the Comptroller General of the United States shall submit to Congress a report containing— (1) an analysis of compliance with the amendments made by this section; (2) an analysis of enforcement of such amendments; (3) recommendations with respect to improving such enforcement; and (4) recommendations relating to improving public disclosure, and public awareness of, the requirements of such amendments.
Where it is
In the House.