I 

116TH CONGRESS 

1ST SESSION H. R. 4946 

To amend title XVIII of the Social Security Act to ensure equal access 

of Medicare beneficiaries to community pharmacies in underserved areas 

as network pharmacies under Medicare prescription drug coverage, and 

for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

OCTOBER 31, 2019 

Mr. WELCH (for himself, Mr. GRIFFITH, Mr. LOEBSACK, Mr. CARTER of 

Georgia, Mr. GONZALEZ of Texas, Mr. CRAWFORD, Mr. WESTERMAN, 

Mr. DAVID P. ROE of Tennessee, Mrs. RODGERS of Washington, Mrs. 

AXNE, Mr. ALLEN, and Mr. PETERSON) 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 title XVIII of the Social Security Act to ensure 

equal access of Medicare beneficiaries to community 

pharmacies in underserved areas as network pharmacies 

under Medicare prescription drug coverage, and for other 

purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Ensuring Seniors Ac3 cess to Local Pharmacies Act of 2019’’. 

4 SEC. 2. ALLOWING ANY STATE LICENSED PHARMACY SERV5 ING AN UNDERSERVED AREA TO BECOME A 

6 NETWORK PHARMACY UNDER MEDICARE 

7 PRESCRIPTION DRUG COVERAGE. 

8 (a) IN GENERAL.—Section 1860D–4(b)(1)(B) of the 

9 Social Security Act (42 U.S.C. 1395w–104(b)(1)(B)) is 

10 amended— 

11 (1) by striking ‘‘DISCOUNTS ALLOWED FOR

12 NETWORK PHARMACIES.—For’’ and inserting the 

13 following: ‘‘DISCOUNTS ALLOWED FOR NETWORK

14 PHARMACIES.— 

15 ‘‘(i) IN GENERAL.—For’’; and 

16 (2) by adding at the end the following new 

17 clause: 

18 ‘‘(ii) INCLUSION OF PHARMACIES LO19 CATED IN UNDERSERVED AREAS IN NET20 WORKS.—For plan years beginning on or 

21 after January 1, 2020, in the case of a 

22 prescription drug plan that has, in its net23 work of pharmacies, one or more phar24 macies located in a health professional 

25 shortage area (as defined in section 

26 332(a)(1)(A) of the Public Health Service 


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1 Act), in a medically underserved area (ac2 cording to a designation under section 

3 330(b)(3)(A) of the Public Health Service 

4 Act), among a medically underserved popu5 lation (as defined in such section 

6 330(b)(3)(A) of such Act), or in a rural 

7 area (as defined by the Federal Office of 

8 Rural Health Policy), and that provides a 

9 reduction in coinsurance or copayments de10 scribed in clause (i) for covered part D 

11 drugs dispensed through such pharmacies, 

12 such plan shall extend to any pharmacy lo13 cated in such area or among such popu14 lation the option to be an in-network phar15 macy with respect to such plan under 

16 terms and conditions (including the reduc17 tions described in clause (i)) comparable to 

18 those the plan has agreed upon with other 

19 in-network pharmacies located in such area 

20 or among such population.’’. 

21 SEC. 3. REASONABLE REIMBURSEMENT REQUIREMENTS. 

22 Section 1860D–2(d)(1)(B) of the Social Security Act 

23 (42 U.S.C. 1395w–102(d)(1)(B)) is amended— 

24 (1) by striking ‘‘PRICES.—For purposes’’ and 

25 inserting ‘‘PRICES.— 


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1 ‘‘(i) IN GENERAL.—For purposes’’; 

2 and 

3 (2) by adding at the end the following new 

4 clauses: 

5 ‘‘(ii) REASONABLE REIMBURSE6 MENT.—For plan years beginning on or 

7 after January 1, 2020, a PDP sponsor and 

8 a Medicare Advantage organization shall 

9 ensure that— 

10 ‘‘(I) each prescription drug plan 

11 or MA–PD plan offered by the spon12 sor or organization does not reimburse 

13 a pharmacy or pharmacist an amount 

14 less than the amount that the phar15 macy benefits manager reimburses a 

16 pharmacy benefits manager affiliate 

17 (as defined in clause (iv)) providing 

18 the same pharmacist services; and 

19 ‘‘(II) in no case may the nego20 tiated price for a covered part D drug 

21 furnished by a pharmacy under a pre22 scription drug plan or MA–PD plan 

23 offered by the sponsor or organiza24 tion, be less than such pharmacy’s 

25 cost of purchasing and dispensing 


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1 such drug and providing such other 

2 services associated with furnishing 

3 such drug as may be specified by the 

4 Secretary. 

5 ‘‘(iii) CLAIM REIMBURSEMENT DIS6 CLOSURE REQUIREMENTS.—With respect 

7 to payment made by a PDP sponsor or a 

8 Medicare Advantage organization to a 

9 pharmacy for a covered part D drug fur10 nished by such pharmacy during a plan 

11 year beginning on or after January 1, 

12 2020, such sponsor or organization shall 

13 promptly furnish all pricing components 

14 including the Network Reimbursement ID 

15 used to price the claim, any fees, pharmacy 

16 price concessions, discounts, subsidies, re17 bates, incentives, or any other forms of di18 rect or indirect remuneration that affect 

19 payment and pricing of the claim as part 

20 of the claim adjudication response at the 

21 point-of sale. All pricing components de22 scribed in the preceding sentence shall 

23 each be identified in a predetermined line 

24 item in the remittance advice that is stand25 ard across the industry. The PDP sponsor 


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1 or Medicare Advantage organization shall 

2 include suitable claim-level detail on the 

3 electronic remittance advice that accom4 panies each payment. This claim-level de5 tail shall include, in an industry standard6 ized format, all fields needed to properly 

7 identify the claim, including the Claim Au8 thorization Number, date of service, date 

9 of payment remittance, ingredient cost re10 imbursed, dispensing fee reimbursed, pay11 ment amounts including the Network ID 

12 used to price the claim, the specific dollar 

13 amounts and the appropriate qualifier 

14 codes for each payment adjustment includ15 ing fees, pharmacy price concessions, or in16 centives. 

17 ‘‘(iv) PHARMACY BENEFITS MANAGER

18 AFFILIATE DEFINED.—For purposes of 

19 clause (ii), the term ‘pharmacy benefits 

20 manager affiliate’ means a pharmacy or 

21 pharmacist that directly or indirectly, 

22 through one or more intermediaries, owns 

23 or controls, is owned or controlled by, or is 


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1 under common ownership or control with a 

2 pharmacy benefits manager.’’. 

Æ 


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