I 

118TH CONGRESS 

1ST SESSION H. R. 5393 

To amend title XVIII of the Social Security Act to ensure fair assessment 

of pharmacy performance and quality under Medicare part D, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 12, 2023 

Mr. GRIFFITH (for himself and Mr. CARTER of Georgia) 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 

fair assessment of pharmacy performance and quality 

under Medicare part D, 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, 

3 SECTION 1. ENSURING FAIR ASSESSMENT OF PHARMACY 

4 PERFORMANCE AND QUALITY UNDER MEDI5 CARE PART D. 

6 (a) STANDARDIZED PHARMACY PERFORMANCE

7 MEASURES.—Section 1860D–2 of the Social Security Act 


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1 (42 U.S.C. 1395w–102) is amended by adding at the end 

2 the following new subsection: 

3 ‘‘(f) APPLICATION OF STANDARDIZED PHARMACY

4 PERFORMANCE MEASURES.— 

5 ‘‘(1) MEASURES.—For plan years beginning on 

6 or after January 1, 2025, a PDP sponsor offering 

7 a prescription drug plan and an MA organization of8 fering an MA–PD plan shall, for purposes of incen9 tive payments, price concessions, or any fees or 

10 other remuneration paid or charged to a pharmacy 

11 based on performance measures, only use measures 

12 that are— 

13 ‘‘(A) established or adopted by the Sec14 retary under paragraph (2) and included on the 

15 list described in subparagraph (B) of such 

16 paragraph; and 

17 ‘‘(B) relevant to the performance of such 

18 pharmacy based on the type of pharmacy (in19 cluding retail, mail order, specialty, long-term 

20 care, and home infusion or other types of phar21 macies), drugs dispensed, and pharmacy serv22 ices used to dispense and manage drugs. 

23 ‘‘(2) STANDARDIZED PHARMACY PERFORMANCE

24 MEASURES.— 

25 ‘‘(A) MEASURES.— 


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1 ‘‘(i) IN GENERAL .—Notwithstanding 

2 any other provision of law, the Secretary 

3 shall establish (or adopt pursuant to clause 

4 (iii)) standardized pharmacy performance 

5 measures to be used by a PDP sponsor of6 fering a prescription drug plan and an MA 

7 organization offering an MA–PD plan for 

8 the purpose of determining incentive pay9 ments, price concessions, or fees described 

10 in paragraph (1). 

11 ‘‘(ii) REQUIREMENTS.—The measures 

12 under clause (i) shall focus on pharmacy 

13 performance and quality of care based on 

14 the type of pharmacy, as determined by 

15 the Secretary. Such measures shall be evi16 dence-based, feasible, appropriate and rea17 sonable. The Secretary may rely on data 

18 and information collected from relevant 

19 stakeholders to make determinations about 

20 whether a measure satisfies the require21 ments of this clause. 

22 ‘‘(iii) ADOPTION OF MEASURE.—In 

23 lieu of establishing some or all of the 

24 measures under this paragraph, the Sec25 retary may adopt measures and measure 


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1 performance criteria that are endorsed by 

2 1 or more multi-stakeholder consensus or3 ganizations (such as the Pharmacy Quality 

4 Alliance), that has participation from phar5 macies (including retail and specialty phar6 macies not owned or affiliated with a plan, 

7 pharmacy benefit manager, or other phar8 macy), health plans, pharmacy benefit 

9 managers, and the Centers for Medicare & 

10 Medicaid Services. Any measure adopted 

11 under this clause shall be deemed to meet 

12 the requirements under clause (ii). 

13 ‘‘(B) MAINTENANCE OF LIST.— 

14 ‘‘(i) IN GENERAL.—The Secretary 

15 shall maintain, and publish on a publicly 

16 available internet website, a list of meas17 ures established or adopted under this 

18 paragraph. Such list shall initially be pub19 lished no later than June 1, 2024. 

20 ‘‘(ii) UPDATE.—The Secretary shall 

21 periodically evaluate measures, measure 

22 criteria, and how measures are applied by 

23 type of pharmacy and update the measures 

24 on the list under clause (i) to ensure such 


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1 measures meet the requirements under 

2 subparagraph (A)(ii). 

3 ‘‘(3) OIG REPORTS ON PHARMACY PERFORM4 ANCE MEASURES.— 

5 ‘‘(A) OIG STUDY.—The Office of the In6 spector General of the Department of Health 

7 and Human Services (in this paragraph re8 ferred to as the ‘Inspector General’) shall con9 duct a study of the use of performance meas10 ures and other quality-related mechanisms in 

11 network pharmacy agreements and other rel12 evant contracting arrangements among PDP 

13 sponsors offering a prescription drug plan, MA 

14 organizations offering a MA–PD plan, phar15 macy benefit managers acting on behalf of such 

16 sponsors and organizations, and network phar17 macies. Such study may include audits, reviews 

18 of relevant enforcement actions, consultation 

19 with relevant stakeholders, and other activities 

20 determined appropriate by the Inspector Gen21 eral, consistent with other provisions of law. 

22 Such study shall, to the extent feasible, include 

23 analysis of— 

24 ‘‘(i) oversight and enforcement activi25 ties undertaken with respect to current 


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1 statutory and regulatory requirements re2 lated to network pharmacy agreements, in3 cluding under sections 423.505(b)(18) and 

4 423.505(i) of title 42 of the Code of Fed5 eral Regulations (or any successor regula6 tion) and under section 1860D–4(b)(1)(A); 

7 ‘‘(ii) penalties or other corrective ac8 tions imposed with respect to the require9 ments described in clause (i); 

10 ‘‘(iii) the prevalence of the application 

11 of performance measures in network phar12 macy agreements, and the manner in 

13 which such measures are applied, including 

14 variation based on the type of pharmacy, 

15 the type of drug dispensed, and the serv16 ices required to manage and dispense such 

17 drug; 

18 ‘‘(iv) the extent to which the perform19 ance measures and related criteria applied 

20 under network agreements vary among 

21 similar types of pharmacies within a single 

22 network, and the extent to which the appli23 cation of such measures or criteria differ 

24 between pharmacies— 


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1 ‘‘(I) affiliated with a pharmacy 

2 benefit manager, a PDP sponsor of3 fering a prescription drug plan, or an 

4 MA organization offering a MA–PD 

5 plan; and 

6 ‘‘(II) those not affiliated with an 

7 entity described in subclause (I); 

8 ‘‘(v) patterns and trends in the per9 formance measures applied under phar10 macy network agreements, including if the 

11 measure is being used in accordance with 

12 published measure specifications which 

13 have been validated and tested, if the 

14 measure is being used according to licens15 ing agreements with measure stewards, 

16 and the level of attribution and attribution 

17 criteria; 

18 ‘‘(vi) the extent to which performance 

19 measures result in incentive payments, 

20 fees, price concessions, or other forms of 

21 remuneration between pharmacies and 

22 PDP sponsors or MA organizations (or 

23 pharmacy benefit managers acting on their 

24 behalf), including an analysis of which 

25 measures most often result in incentive 


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1 payments to pharmacies (and the general 

2 amount of such payments) and which 

3 measures most often result in remunera4 tion paid by pharmacies to other entities 

5 (and the general amount of such pay6 ments); 

7 ‘‘(vii) variation in the type of remu8 neration (as described in clause (vi) result9 ing from the application of performance 

10 measures, including between different 

11 types of pharmacies, different types of 

12 drugs dispensed, and affiliation status of 

13 pharmacies (as described in clause (iv)); 

14 ‘‘(viii) when, in what manner, dif15 ferent types of pharmacies receive notice of 

16 the application of performance measures, 

17 the measures that will be utilized, the per18 formance criteria that will be applied, and 

19 the data and methodologies that will be 

20 used to evaluate performance; and 

21 ‘‘(ix) the extent to which the Centers 

22 for Medicare & Medicaid Services has im23 plemented the pharmacy performance re24 porting requirements of section 

25 423.514(a)(5) of title 42, Code of Federal 


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1 Regulations, the extent to which PDP 

2 sponsors or MA organizations (or phar3 macy benefit managers acting on their be4 half) comply with such provision, and the 

5 extent to which the Centers for Medicare & 

6 Medicaid Services has sought enforcement. 

7 ‘‘(B) OIG REPORTS.— 

8 ‘‘(i) REPORT ON INITIAL FINDINGS.— 

9 Not later than December 31, 2024, the In10 spector General shall submit a report to 

11 Congress outlining, to the extent prac12 ticable, a status update on the study under 

13 subparagraph (A), together with initial 

14 findings with respect to the issues included 

15 under such study. Such report may include 

16 an analysis of barriers to accessing any of 

17 the information required under such study, 

18 along with recommendations for addressing 

19 such barriers. Such report may also in20 clude recommendations for the effective 

21 implementation of the requirements en22 acted under this subsection as well as ex23 isting regulations, including section 

24 423.514(a)(5) of title 42, Code of Federal 

25 Regulations, along with other recommendaVerDate Sep 11 2014 02:48 Sep 13, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H5393.IH H5393

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1 tions, as determined appropriate by the In2 spector General. 

3 ‘‘(ii) INTERIM REPORT.—Not later 

4 than July 31, 2025, the Inspector General 

5 shall submit to Congress an interim report 

6 on the study under subparagraph (A), in7 cluding additional recommendations for the 

8 implementation of the requirements en9 acted under this subsection as well as 

10 under existing regulations, including sec11 tion 423.514(a)(5) of title 42, Code of 

12 Federal Regulations. 

13 ‘‘(iii) FINAL REPORT.—Not later than 

14 December 31, 2025, the Inspector General 

15 shall submit to Congress a final report on 

16 the study under subparagraph (A), to17 gether with additional recommendations, 

18 as determined appropriate by the Inspector 

19 General. 

20 ‘‘(4) NONAPPLICATION OF PAPERWORK REDUC21 TION ACT.—Chapter 35 of title 44, United States 

22 Code, shall not apply to any data collection under23 taken by the Secretary under this paragraph.’’. 

24 (b) FUNDING.—In addition to amounts otherwise 

25 available, there is appropriated to the Centers for MediVerDate Sep 11 2014 02:48 Sep 13, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\H5393.IH H5393

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1 care & Medicaid Services Program Management Account, 

2 out of any money in the Treasury not otherwise appro3 priated, $4,000,000 for fiscal year 2025, to remain avail4 able until expended, to carry out the amendment made 

5 by subsection (a). 

6 SEC. 2. PROMOTING TRANSPARENCY FOR PHARMACIES 

7 UNDER MEDICARE PART D. 

8 (a) TRANSPARENCY FOR PHARMACIES.—Section 

9 1860D–2(f) of the Social Security Act (42 U.S.C. 1395w– 

10 102(f)), as added by section 3, is amended by adding at 

11 the end the following new paragraph: 

12 ‘‘(3) TRANSPARENCY FOR PHARMACIES.— 

13 ‘‘(A) IN GENERAL.—For plan years begin14 ning on or after January 1, 2025, a PDP spon15 sor offering a prescription drug plan and an 

16 MA organization offering an MA–PD plan, with 

17 respect to payment made by such PDP sponsor 

18 or such MA organization to a pharmacy for a 

19 covered part D drug dispensed by such phar20 macy during a plan year, shall promptly fur21 nish, upon receiving a claim for a covered Part 

22 D drug from a pharmacy, to such pharmacy in23 formation related to such claim, such as the 

24 Network Reimbursement ID, fees, pharmacy 

25 price concessions, discounts, incentives, or any 


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1 other forms of remuneration that affect pay2 ment and pricing of the claim. 

3 ‘‘(B) STANDARDIZED FORMAT.—The PDP 

4 sponsor and the MA organization shall furnish 

5 the information described in subparagraph (A) 

6 in a standardized format (as specified by the 

7 Secretary) that includes all fields needed to 

8 price the claim for a covered part D drug dis9 pensed by such pharmacy. 

10 ‘‘(C) IMPLEMENTATION.—The Secretary 

11 shall implement this paragraph by program in12 struction or other forms of program guidance.’’. 

13 (b) FUNDING.—In addition to amounts otherwise 

14 available, there is appropriated to the Centers for Medi15 care & Medicaid Services Program Management Account, 

16 out of any money in the Treasury not otherwise appro17 priated, $2,000,000 for fiscal year 2025, to remain avail18 able until expended, to carry out the amendment made 

19 by subsection (a). 

Æ 


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