Pharmacy Benefit Manager Sunshine and Accountability Act

Subjects: Health


<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2816 Introduced in House (IH)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                H. R. 2816

To amend title XI of the Social Security Act to strengthen transparency 
        requirements with respect to pharmacy benefit managers.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             April 25, 2023

 Mrs. Harshbarger (for herself, Ms. Spanberger, Mrs. Miller-Meeks, and 
 Mr. Krishnamoorthi) 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 XI of the Social Security Act to strengthen transparency 
        requirements with respect to pharmacy benefit managers.

    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 ``Pharmacy Benefit Manager Sunshine 
and Accountability Act''.

SEC. 2. STRENGTHENING PHARMACY BENEFIT MANAGER TRANSPARENCY 
              REQUIREMENTS.

    Section 1150A of the Social Security Act (42 U.S.C. 1320b-23) is 
amended--
            (1) in subsection (a)--
                    (A) in paragraph (1), by striking ``; or'' and 
                inserting a semicolon;
                    (B) in paragraph (2), by striking the comma at the 
                end and inserting ``; or''; and
                    (C) by adding at the end the following new 
                paragraph:
            ``(3) a group health plan or health insurance issuer 
        offering group or individual health insurance coverage (as such 
        terms are defined in section 2791 of the Public Health Service 
        Act),'';
            (2) by amending subsection (b) to read as follows:
    ``(b) Information Described.--The information described in this 
subsection is the following with respect to services provided by a 
health benefits plan or PBM for a contract year:
            ``(1) With respect to a contract with each entity described 
        in paragraphs (1) through (3) of subsection (a), the aggregate 
        dollar amount of all--
                    ``(A) rebates that a PBM or health benefits plan 
                received under each such contract from all drug 
                manufacturers;
                    ``(B) administrative fees that a PBM or health 
                benefits plan received under each such contract with 
                from all drug manufacturers;
                    ``(C) administrative fees that a PBM or health 
                benefits plan received under each contract from each 
                such entity;
                    ``(D) rebates that a PBM or health benefits plan 
                received under each contract with each entity from all 
                pharmaceutical manufacturers that were not passed 
                through to such entities;
                    ``(E) administrative fees that a PBM or health 
                benefits plan received under each contract from all 
                pharmaceutical manufacturers and did not pass through 
                to such entities;
                    ``(F) total post-claim adjudication payments that a 
                PBM or health benefits plan collected from a pharmacy 
                under each contract, including any fees, 
                reimbursements, or other claw backs including generic 
                effective rate and brand effective rate contracts; and
                    ``(G) any post-claim adjudication payments that a 
                PBM or health benefits plan collected from a pharmacy 
                under each contract, including any fees, 
                reimbursements, or other claw backs including generic 
                effective rate and brand effective rate contracts that 
                were not passed through to such entities.
            ``(2) The aggregate retained rebate percentage under each 
        contract (that is the value in paragraph (1)(D) divided by the 
        value in paragraph (1)(A)).
            ``(3) Across all contractual relationships for each PBM 
        whereby such PBM is managing prescription drug coverage for a 
        entity described in in paragraphs (1) through (3) of subsection 
        (a), the highest retained rebate percentage and lowest retained 
        rebate percentage for each contract under which such PBM 
        provided services.'';
            (3) in subsection (c)--
                    (A) in the matter preceding paragraph (1), by 
                striking ``, plan, or prices charged for drugs,'' and 
                inserting ``or plan, the prices charged for a specific 
                drug or classes of drugs, or the amount of any rebates 
                provided for a specific drug or classes of drugs,''; 
                and
                    (B) by adding at the end the following new 
                paragraph:
            ``(5) To carry out the reporting requirement under 
        subsection (e).''; and
            (4) by adding at the end the following new subsections:
    ``(e) Public Reporting Requirement.--Not later than the first 
calendar quarter following the first full plan year beginning on or 
after the date of enactment of this subsection, and annually 
thereafter, the Secretary shall publish on a public website of the 
Department of Health and Human Services the information reported under 
subsection (b), in accordance with the confidentiality requirements 
described in subsection (c).
    ``(f) Definitions.--In this section:
            ``(1) Brand effective rate.--The term `brand effective 
        rate' means the claim reimbursement for a brand name drug, 
        expressed as a percentage discount from the average wholesale 
        price of such drug.
            ``(2) Generic effective rate.--The term `generic effective 
        rate' means the claim reimbursement for a generic drug, 
        expressed as a percentage discount from the average wholesale 
        price of such drug.
            ``(3) Pharmacy benefits manager.--The term `pharmacy 
        benefits manager' or `PBM' means--
                    ``(A) an entity that manages prescription drug 
                benefits on behalf of an entity described in paragraphs 
                (1) through (3) of subsection (a); and
                    ``(B) for purposes of this section, includes any 
                other organization that--
                            ``(i) has directly or indirectly (as 
                        determined by the Secretary in regulations), an 
                        ownership interest of 5 percent or more in the 
                        PBM;
                            ``(ii) shares, or is otherwise a part of, 
                        the same organizational structure as the PBM;
                            ``(iii) exercises operational, financial, 
                        or managerial control over the PBM or a part 
                        thereof, or provides policies or procedures for 
                        any of the operations of the PBM, or provides 
                        financial or cash management services to the 
                        PBM; or
                            ``(iv) provides management or 
                        administrative services, management or clinical 
                        consulting services, or accounting or financial 
                        services to the PBM.
            ``(4) Organizational structure.--The term `organizational 
        structure' means, in the case of--
                    ``(A) a corporation, the officers, directors, and 
                shareholders of the corporation who have an ownership 
                interest in the corporation which is equal to or 
                exceeds 5 percent;
                    ``(B) a limited liability company, the members and 
                managers of the limited liability company;
                    ``(C) a general partnership, the partners of the 
                general partnership;
                    ``(D) a limited partnership, the general partners 
                and any limited partners of the limited partnership who 
                have an ownership interest in the limited partnership 
                which is equal to or exceeds 5 percent;
                    ``(E) a trust, the trustees of the trust; or
                    ``(F) any other person or entity as the Secretary 
                determines appropriate.''.
                                 &lt;all&gt;
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