Pharmacists Fight Back [in Federal Employee Health Benefit Plans Act]

[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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